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Two operative approaches for esophageal carcinoma were compared with respect to operative morbidity and mortality by means of multivariable analysis. From 1980 to 1986, 152 patients underwent resection by laparotomy and right-sided anterolateral thoracotomy with an intrathoracic anastomosis. From 1986 to 1989, 141 patients underwent resection by transhiatal blunt dissection with a cervical anastomosis. The stomach was the preferred organ for reconstruction. Paresis of the recurrent laryngeal nerve and leakage of the cervical anastomosis occurred significantly more often in the transhiatal group. Pulmonary complications occurred less frequently in the transhiatal group. In-hospital mortality (9% in the thoracotomy group and 5% in the transhiatal group) increased significantly with advanced age of the patients. Furthermore, it was significantly higher in case of colonic interposition as compared with reconstruction with the stomach. Long-term survival did not differ between the two groups. Especially for carcinomas in the distal part of the esophagus, transhiatal esophageal resection without thoracotomy seems to be an oncologically justifiable operation with a reduced morbidity and mortality.

The ability of preoperative CT to assess resectability and to stage carcinoma of the esophagus and gastroesophageal junction was studied in 71 patients who underwent transhiatal esophagectomy. Patients with preoperatively proven distant metastases who did not have surgery were not included in the present study. At surgery the tumor invaded adjacent mediastinal or abdominal structures in 18 patients (prevalence 25%), but was nonresectable in only 7 of these 18 patients (39%). Invasions of the tracheobronchial tree, the aorta, and the diaphragm were correctly detected on CT in 5 of 6, 1 of 2, and 2 of 10 patients. There were four false-positive results on CT; tracheobronchial invasion and pericardial invasion were incorrectly predicted in one and three patients, respectively. Invasion of adjacent structures was correctly assessed on CT in 58 (82%) patients and the depth of tumor invasion was correctly determined in 49 (69%) patients. Computed tomography correctly staged 57% of patients according to the classification of the American Joint Committee on Cancer. Understaging (31%) occurred more often than overstaging (11%). In the present study, computed tomography was not effective in assessing non-resectability by diagnosing invasion because of the relatively low prevalence of invasion of adjacent structures and the fact that invasion was often not associated with nonresectability. In assessing invasion itself, CT was accurate in diagnosing tracheobronchial involvement, but was limited in diagnosing invasion of other adjacent structures. In assessing stage grouping, CT was limited in detecting either diaphragmatic invasion or lymph node involvement.

The purpose of the study was to evaluate ultrasound and computed tomography in the assessment of distant metastases, supraclavicular and abdominal, in 113 patients with carcinoma of the oesophagus and gastrooesophageal junction. Ultrasound and computed tomographic findings were compared with the cytological data in 29 patients and with the surgical data in 84 patients. In assessing distant metastases, ultrasound and computed tomography had a sensitivity of 61% and 70%, and a specificity of 93% and 85%, respectively (p = 1.0). When ultrasound and computed tomography were combined the sensitivity increased to 83% and the specificity decreased to 81%. There was no significant difference in the assessment of supraclavicular metastases (p = 0.8), coeliac metastases (p = 1.0) or liver and other non-lymphatic abdominal metastases (p = 1.0) on ultrasound or computed tomography. The results show that both ultrasound and computed tomography should be used for assessment of distant metastases and abnormalities confirmed by image-guided biopsy.

The T stage is an important criterion for determining prognosis in esophageal carcinoma. Endosonography, although established as a highly accurate method in preoperative determination of the T stage, may be less reliable in non-traversable tumor stenoses. In a comparative prospective study, 41 patients with carcinoma of the esophagus were investigated to determine the role of tumor stenosis on the accuracy of endosonography in preoperative T staging. The results were correlated with the histology of the resected specimen. The overall accuracy in T staging with endosonography was 76%, compared with 49% in computed tomography. T staging results of endosonography were good in easily and non-traversable stenoses (92%, 87% respectively), but lower accuracy was obtained in stenoses which could be traversed only with difficulty (46%). Computed tomography was inferior to endosonography in all three groups of patients. The high accuracy of endosonography in non-traversable stenoses might be due to the fact that all tumors were in an advanced stage (T3 or T4). When passage of the echoendoscope proves difficult, the low focal distance between the ultrasonic transducer and tumor may hamper clear visualisation of the wall layers and tumor penetration depth. These limitations of endosonography should stimulate further efforts in improving ultrasonic resolution in these cases.

A retrospective study was performed of an 11 year period (1978-88) to analyse the survival of 112 patients (85 men and 27 women, mean age 63 years) with adenocarcinoma in a columnar lined (Barrett's) oesophagus in respect of surgical treatment, tumour staging, and histological grading. Presenting symptoms were dysphagia (60%) and pain (25%). Only six patients were previously known to have a columnar lined oesophagus. Eighty five patients (76%) underwent partial resection of the oesophagus and cardia. Postoperative mortality was 6%. After resection (n = 85), the 5 year survival was 24%. Survival was significantly better for patients without regional lymph node metastases (stage 0, I, IIA (n = 61): 5 year survival 30%) and even better if the tumour was restricted to the submucosa (stage 0, I (n = 12): 5 year survival 63%). Survival was not influenced by the histological grade of the tumour. Staging based on infiltration of the oesophageal wall and lymph node spread is valuable in determining the prognosis for patients with adenocarcinoma in Barrett's oesophagus.

The use of ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) for the assessment of distant metastases was prospectively studied in 135 consecutive patients with carcinoma of the esophagus and gastroesophageal junction. Patients with accessible lesions on US and computed tomographic (CT) studies of the supraclavicular regions and the abdomen underwent US-guided FNAB. In patients with multiple lesions biopsies were preferentially performed on enlarged supraclavicular nodes. Forty-nine patients underwent US-guided FNABs of 53 lesions. A cytologic diagnosis was established in 46 of 53 (87%) biopsies. Seven of 53 (13%) biopsies were nondiagnostic. Distant metastases were diagnosed by means of cytologic study in 33 of 135 (24%) patients. Supraclavicular metastases were diagnosed in 22 patients and abdominal metastases were diagnosed in 12 patients, including one patient who also had supraclavicular metastases. US-guided FNAB can improve the selection of patients for surgical and nonsurgical treatment by diagnosing distant metastases in an important number of patients.

Between January 1, 1983, and December 31, 1988, operations were performed on 112 patients with adenocarcinoma of the gastric cardia. Resection of the primary tumor was performed in 93 patients. For these 93 patients, follow-up until July 1, 1989, averaged 24 months, during which time 59 patients died. Positive resection margins carried a greater risk for the development of a local recurrence but did not correlate with survival. The cumulative overall 5-year actuarial recurrence rate was 69%. The cumulative 5-year recurrence rate for metastases was 64% and for locoregional recurrence it was 36%. The overall 5-year survival rate was 24%. Differences in survival were observed between patients with carcinomas of the various subgroups of the 1987 TNM classification system (T1-T2 versus T3-T4, N0 versus N1-N2, M0 versus M1, Stages I-II versus Stages III-IV, Grades 1-2 versus Grades 3-4). In particular, lymph node status as correlated with histopathologic grade showed remarkable differences in survival: patients with no positive lymph nodes in the resection specimen and a Grade 1 or 2 tumor had a significantly better 5-year survival rate (53%) than the other subgroups (N0/Grades 3-4: 21%; N1-N2/Grades 1-2: 12%; N1-N2/Grades 3-4: 14%).

Quality of Life (QL) is hard to assess and seldom measured in patients having carcinomas with an unfavourable prognosis. Oesophageal cancer is one of the malignancies with a low 5-year survival rate. Dysphagia (problems in swallowing food) is considered to be the most important indicator of QL in patients with oesophageal carcinoma. Moreover, the psycho-social aspects and subjective QL in cancer have recently gained importance. The present study investigated QL in a 132 patients with oesophageal cancer. Eighty-three of them had a surgical operation (removal of part of the oesophagus and part of the stomach, followed by a reconstruction of the digestive tract). Sixty-seven patients filled in questionnaires before and after the operation. Complete sets of data were obtained from 62 patients. Time interval between operation and postoperative assessment varied from 3 to 7 months. Indicators of QL were: Psychological Distress, Physical Symptoms, Global Evaluations, Activity Level, Swallowing Problems and Food Intake. Swallowing Problems showed moderate correlations with the other QL indicators. Physical Symptoms increased, whereas the Activity Level, Psychological Distress, and Swallowing Problems decreased; Global Evaluations remained unaltered.

To determine the incidence of oesophageal carcinoma in patients with achalasia and to establish the efficacy of endoscopic surveillance, 195 consecutive patients with achalasia (90 men and 105 women, mean age 52 years), who were treated by pneumatic dilatation in our institution between 1973 and 1988 were prospectively studied. None of the patients had undergone cardiomyotomy. Follow up totalled 874 person years after pneumatic dilatation. In this period three patients developed an oesophageal squamous cell carcinoma. The mean age at diagnosis of the oesophageal carcinoma was 68 years (37, 77, and 89 years). The mean period between the onset of dysphagia and the diagnosis of the tumour was 17 years (19, 28, and 5 years); the mean interval between the diagnosis of achalasia and carcinoma was 5.7 years (5, 8, and 4 years). The incidence of oesophageal squamous cell carcinoma in this series (3.4/1000 patients per year) is significantly higher than the statistically expected incidence (0.104/1000 patients per year) using age and sex specific incidence data from the population of the Netherlands (Poisson statistics: p less than 0.001). The risk of developing oesophageal squamous cell carcinoma in patients with achalasia is therefore increased 33 fold. Periodic endoscopy showed the potential for detecting early stage oesophageal carcinoma in two cases but a larger study with a longer follow up is required to determine the efficacy of endoscopic screening in improving the prognosis for patients with achalasia who develop oesophageal squamous cell carcinoma.

Perforation of the oesophagus was retrospectively analysed in 59 patients. Cause and extent of perforation, localization, quality of the oesophageal wall and therapeutic modes were subjected to univariate analysis. The perforations of the intrathoracic oesophagus (39) were also subjected to multivariate analysis. Perforation of the cervical oesophagus is seldom lethal and can be adequately treated conservatively in the majority of cases. Perforations of the intrathoracic oesophagus can be divided into two groups, with or without simultaneous perforation of the parietal pleura. The optimal treatment for the group with pleural perforation seems to be resection of the oesophagus and secondary reconstruction, although primary closure is indicated in selected early cases. Perforations of the intrathoracic oesophagus confined to the mediastinum can be adequately treated conservatively in most patients. Perforation of the intra-abdominal oesophagus should be treated like any other intra-abdominal visceral perforation, by closure or diversion, even if this results in resection of the oesophagus.

The preoperative assessment of supraclavicular lymph node metastases was prospectively studied in 100 patients with carcinoma of the esophagus and gastroesophageal junction. Findings at computed tomography (CT), ultrasound (US), and palpation were compared, and US-guided fine-needle aspiration biopsy of nodes with a small axis of 5 mm or greater was performed. Supraclavicular metastases were detected on CT scans in 11 of 13 patients (85%) and on US scans in 14 of 16 patients (88%) but were palpable in only three of the 16 patients (19%). The predictive value of a supraclavicular node indicating metastases was .74 at US and .85 at CT. Metastases were diagnosed in 10 of 46 patients with squamous cell carcinoma (22%) and five of 50 patients (10%) with adenocarcinoma. Nodes with metastases had a round configuration, with a statistically significant greater short-axis to long-axis ratio than that of benign nodes (0.89 vs 0.54; P = .05). In four of 16 patients (25%) with supraclavicular metastases proved with cytologic examination, neither CT nor US of the mediastinum and abdomen showed enlarged nodes.

The use of ultrasound combined with ultrasound-guided fine-needle aspiration biopsy (UGFAB) of supraclavicular lymph nodes in the pretreatment staging of 37 patients with squamous cell carcinoma of the esophagus is described. All patients underwent computed tomography (CT) scans of the chest and the abdomen and ultrasound of the abdomen and supraclavicular regions. Supraclavicular lymph node metastases (Stage IV disease according to the tumor nodes metastasis [TNM] classification) were cytologically diagnosed in seven (18.9%) of the 37 patients. In two of these patients, no other metastases were found. In the other five patients, UGFAB replaced more invasive diagnostic procedures. Due to their superficial location, ultrasound and UGFAB of the supraclavicular lymph nodes was relatively simple to perform, and contributed to an improved staging of squamous cell carcinoma of the esophagus.

25 previously untreated patients with inoperable or metastatic adenocarcinoma of the oesophagus or oesophageal-gastric junction area were treated with ifosfamide 6 g/m2 over 48 hours, combined with mesna 6 g/m2. 1 complete response and 1 partial response were seen among 23 patients evaluable, with a response duration of 29+ months and 7 months, respectively. Toxicity was not severe: grade 3 infection in 2 patients, grade 3 leucopenia in 3 patients and grade 3 nausea in 4 patients. No life-threatening episodes or central nervous system toxicity were encountered. Ifosfamide has limited activity in adenocarcinoma of the oesophageal-gastric junction area.

From November 1, 1986 to December 1, 1989, 100 patients with squamous cell carcinoma (n = 35), adenocarcinoma (n = 61) or 'other' carcinoma (n = 4) of the oesophagus or the gastroesophageal junction were resected and reconstructed. There were 71 men and 29 women with a mean age of 63 years (35-77 yrs). In 80 patients the tumour was localised in the distal oesophagus or the gastroesophageal junction. In 20 patients the tumour was localised more proximally. In all patients the oesophageal resection was performed transhiatally without thoracotomy with blunt dissection. Reconstruction was performed with a stomach tube (n = 84) or colonic interposition (n = 16). Postoperative pulmonary complications were seen in 25% of the patients. Leakage of the cervical anastomosis was seen in 6 patients. In-hospital mortality was 4%. Oesophageal resection without thoracotomy appears to be an operation with reduced morbidity leading to a marked decrease in postoperative mortality.

181 patients undergoing resection of the oesophagus for carcinoma were randomised to receive selective decontamination (test group) or conventional perioperative antibiotic prophylaxis (controls). 114 patients were finally included in the study: 12 of 56 test patients had 18 infections, whereas 32 of 58 controls acquired 51 infections. Colonisation with aerobic gram-negative microorganisms, and the number of postoperative respiratory tract infections were significantly lower in the test patients. The postoperative therapeutic use of antibiotics was significantly lower in the test group. No endogenous infections were caused by gram-negative bacilli in the test group. Selective decontamination reduces colonisation with gram-negative bacilli and postoperative infections after resection of the oesophagus.

Signs and symptoms of Cushing's syndrome developed rapidly after total gastrectomy in a 37-yr-old man with a metastatic gastrin-secreting islet cell carcinoma. Argyrophilic tumor cells in a lymph node removed during operation immunostained for gastrin and ACTH. Treatment for more than 6 months with the somatostatin analog SMS 201-995 (300 micrograms/day) greatly reduced serum gastrin levels and normalized plasma ACTH and cortisol levels and urinary cortisol excretion, and the signs and symptoms of Cushing's syndrome disappeared. The size of the primary tumor in the head of the pancreas, which had grown rapidly before SMS 201-995 therapy, stabilized after 6 months of treatment with the analog. We conclude that SMS 201-995 can reduce ACTH as well as gastrin secretion from islet cell carcinomas as well as control tumor growth.

To evaluate the patency of PTFE (Gore-tex) as a femoropopliteal bypass, a prospective randomized trial was performed between PTFE and saphenous vein. Forty-nine consecutive patients with intermittent claudication, rest pain, or tissue loss due to an occlusion of the superficial femoral artery entered the study. Randomization between PTFE and saphenous vein was performed at the time of operation after assessment of the quality of the latter. The two groups did not differ significantly regarding stage of peripheral ischemia, outflow tract, or localization of the distal anastomosis. The patency rate 6 weeks after operation was 92% for each group. After a mean follow-up of 54 months, the patency rate for the PTFE group was 37% and 70% for the saphenous vein group (p less than 0.001). In the PTFE group, there were eight major amputations. No amputations were performed in the saphenous vein group. It is concluded from this study that the saphenous vein is by far superior to PTFE as a femoropopliteal bypass.

Fifty PTFE (Goretex) femoropopliteal bypasses were performed for intermittent claudication (23 pts), rest pain (12 pts) or loss of tissue (15 pts). Thirty-one grafts occluded during the follow-up period up to 39 months, 19 grafts were patent. The two groups are compared regarding severity of ischaemia, outflow tract, distal anastomosis and ankle brachial ratio. Except for the severity of ischaemia, these factors showed a statistically significant difference between the two groups. A total of 51 reoperations were performed on 31 thrombosed grafts. Only one of the 24 thrombectomies was successful. A new PTFE or composed grafts never remained patent during the follow-up. Only four of the eight new venous bypasses had a long-term patency. Thrombosis of 31 PTFE femoropopliteal bypass led to amputation in 14 cases.

During a 7-year period 20 patients underwent operation for a graft-enteric fistula after implantation of an intra-abdominal vascular prosthesis months or years before. Eighteen patients had gastrointestinal blood loss as their first symptom; 12 were in shock on admission. Fourteen patients had a fistula between the proximal anastomosis and the duodenum. Graft excision followed by axillobifemoral bypass was performed in 10 patients and four patients underwent local repair. A fistula between the distal anastomosis and the bowel was found in the remaining six patients and a local repair was carried out. Proximal graft-enteric fistula carries a particularly high postoperative mortality rate of more than 50 per cent.