Reprint from Nortwest Medicine, Seattle, Vol. XXVIII, No. I, Page 25, January, 1929 CARCINOMA OF THE ESOPHAGUS* J. EARL ELSE, M.D. PORTLAND, ORE. Clinical Professor and Cairman, Department of General Surgery, University of Oregon Medical Scool Te deat rate from cancer increased from sixtytree per undred tousand in 1900 to ninety-one and nine-tents per undred tousand in 1924, making an increase of nearly forty-six per cent in twenty-four years. Tis is probably partly due to better diagnosis and partly to a iger percentage of postmortem examinations. Yet tis does not account for all. Tere as been an absolute increase in te number of deats from cancer. Wenever tere is a persistent endeavor on te part of te profession to discover a metod of controlling a disease, results are always obtained. Sometimes te result comes quickly, and in oter instances it comes after long and laborious study as been made. Te exact cause of a malady need not necessarily be known in order to control it. Smallpox is an absolutely preventable disease and as been since te days of Jenner, altoug its cause is not known even at te present day. Because we do not know te exact cause of cancer is no reason wy pysicians sould sit idly by, wile te researc men are searcing for it. We know tat cronic irritation of epitelial structures 'Read before te Fifty-fourt Annual Meeting of Oregon State Medical Society, Portland, Ore., Sept. 20 27, 1928.
leads to cancer. We know tat radical removal of a primary growt before metastasis as occurred results in a cure. In te ligt of our present knowledge te prevention and control of cancer consi~ts, first, in a removal of all irritating processes wic may lead to its developument and, second, t~e earl! removal of malignant growt. To accomplis tis requires education of bot te profession and te layman, as to te importance of early examination and early radical irradication of te malignant process. A report of te Pennsylvania cancer commission sows te need and value of suc education. In 1910 te average time elapsing between te first symptom and te operation in superficial cancer was eigteen monts. In 1923 tis ad been reduced to fourteen and six-tents monts. In 1910 te average time elapsing in superficial cancer, between te first consulting of a pysician and te operation, was tirteen monts. In 1923 tis ad been reduced to four and a alf monts. For deep cancer te average time between te first symptom and te operation in 1910 was fourteen monts. In 1923 tis ad been reduced to eigt monts. Te average time between first consulting a pysician and te operation in 1910 was twelve monts, and in 1923 was tree and nine-tents monts. Tis improvement as come as a result of education, but it still sows a need of furter education, for te average time between te consultation of a pysician and te proper treatment of a superficial cancer was still four and one-alf monts in 1923, and for deep cancer was tree and nine-tents monts. Tis gives entirely too muc time for metastasis to occur. I ave cosen to discuss carcinoma of te esopagus as it is generally looked upon as one of te opeless carcinomas, and te patients are often advised, wen te diagnosis is made, tat tere is noting to do but wait for te termination. Wile it is true tat in a considerable proportion cure is impossible, yet tere is muc to be done to relieve te patient of suffering and to prolong life, and make it more endurable. Tere are some tat can be cured. I believe also tat tere is muc tat can be done in te prevention of cancer of te esopagus. Statistics from various autorities sow tat carcinoma of te esopagus occurs in from four and a alf to twelve per cent of all carcinomas. Eigtytwo per cent occurs in men, wile eigteen occurs in women. Tis great preponderance in men means tat tere is someting tat exists in tem and not in women tat serves as an important etiologic factor. In going over clinical records it is found tat te esopagus of men is subject to two irritating substances more frequently tan tat of women, viz., alcool and tobacco. Regardless of wat one ",rould like to believe, facts must be taken. Te use of tese two irritants is te only striking difference and possible etiologic factor existing ~etween men and women. Terefore, in te ligt of our present knowledge, I cannot see ow any oter conclusion can be made tan tat tese two irritants are responsible for a considerable proportion of te additional sixty-four per cent of cancer found in te esopagus of men. So long as men will disregard tat wic tey know to be for te 2
best interest of ealt and continue to use two irritant substances because of a transitory, pleasurable sensation produced by te effect of tese powerful drugs, cancer of te esopagus is going to be far more prevalent in tem tan in women, unless modern women assume to an equal degree tese detrimental abits of men. Of te carcinomas of te esopagus, twelve and tree-tents per cent is found in te upper tird, sixty and eigt-tents at te bifurcation of te tracea and twenty and nine-tents per cent in te lower tird, eigteen per cent of wic are at te cardia. Te cancer is usually of te squamous cell type, but adenocarcinoma also occurs, in wic case it resembles tat of te stomac in appearance. It usually presents a flat infiltrating ulcer, but not infrequently tere is a bulky, projecting mass. Tis latter type is usually of te adenocarcinomatous variety. Te diffuse infiltrating type occurs occasionally. In some tere is marked proliferation of te interstitial connective tissue, giving a typical appearance of scirrous carcinoma. Te earliest symptom is tat of dyspagia, beginning wit solid foods and finally liquids. \Vit te development of te obstruction, tere is a dilatation of te esopagus above and a regurgitation of te food following eating. Early te obstruction is sufficient to prevent passage of only coarser foods. Te patient feels a sense of pressure pains as te larger portions of te food are swallowed. Wit te extension of te process te pain becomes more constant. Te regurgitated food may contain mucus, some blood if tere as been bleeding, and wit ulceration of te growt a foul odor, due to necrosis of te tumor. A diagnosis is made from te istory of te symptoms as outlined. An x-ray study sows encroacment upon te lumen of te esopagus of an irregular type. Esopagoscopy reveals a growt from wic a piece of tissue may be removed. Sounds may be passed for diagnostic purposes and later for treatment. Personally I believe tis process is not surgically sound. Wile it is true tere is no arm for a time, it is also true tat te continual passing of sounds eventually results in a rupture of te esopagus. Treatment tat as been used consists of dilatation, radiation, esopogostomy, gastrostomy and resection. Dilatation is mentioned for te purpose of its condemnation. It is a blind metod and a dangerous one, altoug te danger is minimized by giving a tread wic is allowed to pass out into te intestinal tract and used for a guide. Te use of radium is not giving te result tat was oped for wen it was first introduced. Esopagostomy as proved of value only as a part of te radical operation. Gastrostomy is a procedure tat as given te greatest relief, altoug it never gives a cure. By feeding troug te gastrostomy wound and giving te esopagus a complete rest te secondary inflammatory infiltration is absorbed so tat te stricture often opens, enabling te patient to eat food normally. Following gastrostomy tese patients often gain in weigt, and can go about teir work for some monts. I ad one patient wo, toug muc emaciated at te time of te operation, regained is
normal weigt, and was again able to eat normally witout any apparent difficulty, and carryon is work on a small farm as well as formerly. He considered sljing me for malpractice because is apparent recovery was so complete tat e tougt it impossible for im to ave ad a cancer. He lived over eigteen monts following te gastrostomy. Resection offers te only opportunity for a cure. Wen te carcinoma occurs in te upper portion, its removal is not so difficult, and altoug mortality runs close to twenty per cent, it is justifiable because it offers te only cance of cure and adds to te life and comfort of te majority tat are operated upon. Even in te extensive carcinomato involving te larynx and surrounding structures te patients will often live wit a fair degree of comfort for a year to a year and a alf after te operation. One ~f our patients, in wom an emergency operation was necessary to prevent strangulation, ad more tan an additional year of life, went out on a small farm, were se assumed carge of te cickens and learned to speak so tat se could go sopping. Se felt appy and contented for approximately a year. Te operation for radical removal of carcinoma of te esopagus witin te cest may be divided into four different types: (1) radical removal wit an esopagostomy above and a gastrostomy below,' connected by a rubber tube, (2) te radical removal wit a formation of a subcutaneous epitelial-lined tube as an artificial esopagus, (3) radical removal wit reconstruction of te esopagus from a trans~ plant skin flap, (4) reconstruction of te esopagus by use of a portion of te intestine or te stomac, (5) transplantation of te stomac or a portion of it upward, (6) transplantation of t~ diapragm upward, so tat te lower end of te esopagus becomes an abdominal organ. Te most striking illustration of esopagostomy and gastrostomy connected by a tube was in Torek's case, in wic te patient lived for about tirteen years, and died from pneumonia. Lilientall successfully reconstructed te esopagus after removal of a portion by transplanting a skin tube. Te patient lived about eigt monts and died of recur- renee. Leeding suggested te abdominal metod, bringing te esopagus down, closing te cardia, and ten anastomosing te esopagus to te fundus. Mickulicz improved tis by first obtaining better exposure troug te turning up of te costal arc on te left side and, second, transplanting of te diapragm upward. Heuer as recently elaborated a metod of securing greater transplantation of te diapragm. Volker, Kuffell and Burcer ave eac ad successful cases operated on by tis metod. Zaaiger and Hedbloom ave ad operative successes by te combined abdominal and toracicmetod In te department of surgery at te University of Oregon we 'ave been working on an operation for carcinoma bot at te lower end of te esopagus and te middle tird. Our work as been upon dogs and up to te present time our cief difficult.y as been wit anestesia, as te dog's mediastimum is so tin tat collapse of te rigt lung occurs if positive pressure is not employed. We ave been using te transpleural metod of approac, making an incision in te eigt intercostal and resection
' d sevent ribs posteriorly so of te fift,. Sl~: r::racted upward, Te opening tat tey can't etced and te stomac in te diapragm IS s r transplanted upward.. ' ff te mediastinum wit gauze After waii mg 0 d., 'k d up freed, an t e p remc te esopagus IdS ~IC ; te 'esopagus, Te esopanerves separate ro 'd ' t, d t te cardia an at a porn ten IS clampe a " gus, d te intervenrng portion reb t 7 cm lg er an, a ou,, I'nserted into te antenor d A silk suture IS, move, bout 2 cm, below te onfice 11 f te stomac a 'fi wa 0, nd brougt troug te on ce, of te cardia, a bout 1 cm, above te cut ' te esop agus a catc mg troug te mucosa d T needle does not go. en, e f. fection, It is ten carned b f danger 0 m ecause 0 dl'a and run out troug te d t ug t e car. own ro, b ut 1 cm. from were It en at a pornt a 0, stomac., are inserted in te postenor ed Similar sutures ter., 1 and greater curvatur". T ese 11 d m t e esser wa an t bringing te esopagus down are drawn tau, d d ' pening of te stomac an troug te car lac 0 tied,, uture is ten inserted, uniting te A continuous s f f t e cardia to te esopagus, t us ous sur ace 0 ser. 1 Te stomac ' IS t en roducing a complete c osure. p k 't tubular in order tat te 1 t d so as to rna e 1 pea,e d' pragm will not dilate and pull portion above tela, ' to te torax. Next t e opente entire stomac m, of te ' is sutured to te stomac. d lap ragm, mg,. t t as in a successful operation Tis IS very Impor an,, d perfect ealrng of te anas- Pon one dog we a, '1 b u, d later died from rntestrna 0- tomosls but t e og. b, d to a loop of jejunum passmg up y structlon, ue te stomac into te torax. Te operation of carcinoma in te middle tird is done in tree stages. At te first operation an incision is made in te stomac after putting on clamps parallel to te greater curvature, beginning on te lesser curvature at a point one and a alf cm. from te cardia, and extending down for nearly alf te lengt of te stomac. Te margins are ten sutured, tus making a tube continuous wit te esopagus, extending down to about te middle of te greater curvature and a more or less triangular pouc wic is brougt troug te abdominal wall for a gastrostomy. At te second stage te cest is opened, Te incision is made in te eigt interspace and te fift, sixt and sevent ribs resected posteriorly, Te esopagus is freed and te gastric tube brougt into te torax until te stomac rests against te diapragm. Te diapragm is ten sutured at te base of te tube. Gauze is packed about te esopagus in order to produce a walling off sufficient to prevent infection of te mediastinum, and te tract closed witout drainage, After five days te cest is again open'ed and a portion of te esopagus is resected, Our work for carcinoma of te esopagus is in a purely experimental state. We are not ready at tis time to do any work for patients at all, but I believe as a result of experimental work being carried on,ere and elsewere, a fairly safe approac for te treatment of a malady, tat until te present time is oterwise always fatal, will be developed. Metl'opolitan Pl'ess, Seattle