Eur J Cardiothorac Surg 2005;28:16-18
© 2005 Elsevier Science NL
Comparison of influence of esophageal carcinoma operations on pulmonary function
Jian Hu
a
,*,
Renyuan Li
a
,
Li Sun
b
,
Yiming Ni
a
a Department of Thoracic and Cardiovascular Surgery, First Hospital, Zhejiang University, No 79,Qingchun Road, Hangzhou 310003, China
b School of Medical, Hangzhon Normal College, Hangzhou 310012, China
Received 16 December 2004;
received in revised form 16 January 2005;
accepted 20 January 2005.
* Corresponding author. Tel.: +86 571 8723 6841. (Email: hjsl{at}mail.hz.zj.cn).
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Abstract
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Objective: To study the change of pulmonary function after three kinds of esophageal carcinoma operations. Methods: Esophageal carcinoma operations were performed on 60 consecutive patients, including 20 cases of supra-aortic gastro-esophageal anastomosis, 20 cases of sub-aortic gastro-esophageal anastomosis and 20 cases of apico-thoracic retro-aortic gastro-esophageal anastomosis. Lung function was checked for every patient 3 days before the operation and 3, 6, 12 months after the operation. Results: VC%, FEV1% and MVV% are significantly lower in supra-aortic anastomosis group than in sub-aortic anastomosis group after the operation (P<0.05). VC%, FEV1%, and MVV% are significantly lower in supra-aortic anastomosis group than in apico-thoracic retro-aortic anastomosis group after the operation (P<0.05). VC%, FEV1% and MVV% are not significantly different between apico-thoracic retro-aortic anastomosis group and sub-aortic anastomosis group after the operation (P>0.05). Conclusions: Supra-aortic anastomosis has more negative influence on the post-operative pulmonary function than apico-thoracic retro-aortic anastomosis and sub-aortic anastomosis do.
Key Words: Esophageal carcinoma • Pulmonary function • Radical procedure
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1. Introduction
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There are clear evidences that patients with esophageal carcinoma have relatively good outcomes when treated with resection only, especially through thoracic incision which is easy to remove the regional lymph nodes and to carry out the whole operation [1–3]. Esophageal carcinoma treatment situation in China has its own unique characteristics because of high incidence rates and the larger number of patients waiting for admission. Multimodality treatment with neoadjuvant chemotherapy or chemoradiotherapy was recommended for esophageal carcinoma by some studies but the results are debatable recently by other studies due to poor outcomes at present [4–6]. Surgical therapy is considered the major method for treatment of operable esophageal cancer [1,2]. Yet there are still many post-operative pulmonary complications [7,8]. We try to investigate the influence of different esophageal carcinoma operations on pulmonary function through surveillance of the change of pulmonary function in three groups of cases: supra-aortic gastro-esophageal anastomosis group (supra-aortic group), sub-aortic gastro-esophageal anastomosis group (sub-aortic group) and apico-thoracic retro-aortic gastro-esophageal anastomosis group (retro-aortic group).
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2. Patients and methods
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2.1. Patients and preoperative examination
From May 2002 to May 2003, esophageal carcinoma operations were performed in 60 consecutive patients (42 males, 18 females, 40–72 years-old), including 20 cases of supra-aortic gastro-esophageal anastomosis (supra-aortic group), 20 cases of sub-aortic gastro-esophageal anastomosis (sub-aortic group) and 20 cases of apico-thoracic retro-aortic gastro-esophageal anastomosis (retro-aortic group). Sixty patients consented to participate in the study and were subjected to clinical examination, laboratory tests.Approval from the Committee on Clinical Research of the hospital was obtained.
2.2. Surgical technique
The operations were completed through left muscle-sparing thoracotomy with removal of 6th or 7th rib. Isolation of stomach was achieved through left diaphragm incision. Gastro-esophageal anastomosis was made by assistance of EH40 string suture clamp and 25CDH curved intraluminal stapler (Ethecon-surgery, Inc.). Sub-aortic anastomosis was adopted for lower segment esophageal carcinoma, while middle segment esophageal carcinoma was assigned randomly to supra, ante-aortic anastomosis group or apico-thoracic retro-aortic anastomosis group [9]. 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 esophagus. The string suture was fastened. In apico-thoracic retro-aortic anastomosis group, the proximal end of 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 gastro-esophageal anastomosis was located superior and posterior to the aortic arch, near the top of 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 reducing the possibility of anastomotic leakage (diagrams of the operation, see Ref. [9]). In supra, ante-aortic anastomosis group, the gastro-esophageal anastomosis was made directly anterior to the aortic arch. Esophageal carcinoma was verified by pathological diagnosis for all cases.
2.3. Post-operative management and follow-up
Regular post-operative follow-up was organized in 1, 3, 6, 12 months,with laboratory screening, chest X-ray, CT or endoscopic checking of the anastomosis. During the follow-up of 12 months, no anastomotic leakage or stenosis was found. Antacid and/or antiemetic was applied for three patients of supra, ante-aortic anastomosis group and two patient of sub-aortic anastomosis group due to sustained gastric regurgitation.
2.4. Pulmonary function monitor
Pulmonary function was checked with pulmometer of Master Scope-4.32 (JAEGER, Germany) 3 days before the operation and 3, 6, 12 months after the operation. The patient is required to be totally conscious, sitting down, fasting and well cooperated with. Pulmonary index include Vital Capacity (VC%), First Second Forced Expiratory Volume (FEV1%), and Maximum Ventilatory Volume (MVV%). All data were presented as percentage of actual value to expected value.
2.5. Statistical analysis
Statistical analysis was performed with SPSS for windows 10.0. Results were expressed as mean±S. Differences in each parameter among three groups were analyzed by analysis of variance (F-test). A P-value below 0.05 was considered significant.
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3. Results
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The pre-operative and post-operative pulmonary function data of supra-aortic group, sub-aortic group and retro-aortic group are presented in Table 1
. No significant difference of the index between the three groups is found pre-operatively (P>0.05). The difference of VC%, FEV1%, MVV% between supra-aortic group and sub-aortic group is significant (P<0.05). The difference of VC%, FEV1%, MVV% between supra-aortic group and retro-aortic group is significant (P<0.05). The difference of VC%, FEV1%, MVV% between retro-aortic group and sub-aortic group is not statistically significant (P>0.05).
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4. Discussion
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It has been verified through clinical research that the pulmonary function will decrease obviously after esophageal carcinoma operations [10–12]. Some studies show that the esophageal carcinoma operation with sub-aortic gastro-esophageal anastomosis has similar influence on the post-operative pulmonary function compared with lobectomy of lung vital capacity and maximum ventilatory volume decreased 30 and 27.5%, respectively, 8–12 months after esophageal carcinoma operation, which is comparable with what happened 12 months after resection of half lung [13]. We try to find an ideal procedure with less pulmonary function loss and no sacrifice of the radical treatment purpose through comparison of the influence of three kinds of esophageal carcinoma operations on the long-term post-operative pulmonary function.- 1.
Comparison of supra-aortic group and sub-aortic group. There is no significant difference of the index between the groups before the operation (P>0.05), while the difference of post-operative index between the groups is significant (P<0.05). This means that the thoracic stomach of supra-aortic group has more influence on the pulmonary function than that of sub-aortic group does.
- 2.
Comparison of supra-aortic group and retro-aortic group. There is no significant difference of the index between the groups before the operation (P>0.05), while the difference of post-operative index between the groups is significant (P<0.05). Although the location of gastro-esophageal anastomosis of both groups is above the aortic arch, the thoracic stomach of retro-aortic group locates on the esophageal bed of posterior mediastinum, which less compresses the lung tissue and less reduces the thoracic volume and thus to reduce the influence on the pulmonary function.
- 3.
Comparison of retro-aortic group and sub-aortic group. There is no significant difference of the index between the groups both before and after the operation (P>0.05), suggesting that there is no significant difference of the influence of the groups on the post-operative pulmonary function. But, the retro-aortic group has obviously larger extension of radical procedure than sub-aortic group does.
As a conclusion, supra-aortic group has the largest influence on the post-operative pulmonary function among three groups, while retro-aortic group and sub-aortic group have less influence on it and the difference of the influence between the latter two is not significant. So, we recommend the esophageal carcinoma operation with apico-thoracic retro-aortic gastro-esophageal anastomosis as the prior procedure for treatment of middle segmental esophageal carcinoma, especially upper-middle segmental esophageal carcinoma, for it reduces the loss of pulmonary function after operation without sacrifice of the extension of radical procedure. Thus, the post-operative life quality could be possibly improved.
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Abstract
1. Introduction
