Transcript Document

History Of
Oesophageal Surgery
Mr Dipankar Mukherjee
Consultant Upper GI & Laparoscopic surgeon
QUEENS UNIVERSITY HOSPITAL UK
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This talk
is not about
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Basic science
Non surgical treatment
Benign surgery unless relevant
Endoscopic therapy
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Wide geographical variation
United States
5 cases per 100 000
United Kingdom
7-10 cases per 100000
Iran, China, and Russia
over 500 cases per 100 000
Blot WJ. Epidemiology of esophageal cancer. In Roth JA, RuckdeschelJC, Weisenburger TH, eds.
Thoracic oncology. Philadelphia: WBSaunders, 1989;295
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Rise of adenocarcinoma in Barretts…
30 years ago 10% of oesophageal cancers, it now
represents
approximately 50% to 70% in the western world
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1862
Edwin Smith papyrus
3000 to 2500 BC
….The first report
Case 28 of the 48 cases described in this work was entitled
"A Gaping Wound of the Throat Penetrating the Gullet"
"...if thou examinest a man having a gaping wound in his
throat, piercing through to his gullet; if he drinks water he
‘chokes’ (and) it comes out of the mouth of his wound; if it is
greatly inflamed so that he develops fever from it, thou
shouldst draw together that wound with stitching..."
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Greece
Rome
Dark age
Islam
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Byzantine Era
Paul of Aegina (about 620690)Alexandrian school
amputation of the breast for cancer, extirpation of
the uterus
Tonsillectomy
tracheotomy
Removal of foreign body from oesophagus
some of his descriptions of complicated and
difficult operations have been little improved upon
even in modern times
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Challenges:
h
The anatomic remoteness of the thoracic
oesophagus
Physiologic challenge of intraoperative control of
respiration
The history of oesophageal surgery is the tale of men
repeatedly losing to a stronger adversary yet persisting in this
unequal struggle until the nature of the problems became
apparent and the war was won.
Emslie 1988
Perspectives in the Development of Oesophageal Surgery
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1633 Ambrose Pare
when the oesophagus was being sutured great care
should be taken.
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Hermann Boerhaave (1668-1738)
post-mortem examinations to find the cause of fatal
illnesses
use of the Fahrenheit thermometer
The syndrome that is named after him he described
in 1724
when Grand Admiral of the Dutch Fleet and Prefect
of Rhineland Baron J van Wassenaer died soon after
developing chest and abdominal pain after vomiting
on a full meal.
Boerhaave performed a post-mortem and identified
an oesophageal rupture with spillage of gastric
contents into the mediastinum (Boerhaave's
syndrome
1738 Goursaud and Roland
Cervical oesophagotomy for FB removal
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Leeuwen howek1670
microscope
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Ignaz Semmelweis
Vienna1848
Observation:Friend died of autopsy wound
Measurement:Physicians 10%
Midwives 3%
Hypothesis :"cadaveric particles."
Smell not removed by hand washing, but calcium
hypochlorite:
Result:Ca(OCl)2 reduced puerperal fever
death rate 12.4% to 1.27%.
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Joseph Lister 1860 antisepsis
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LATE 19TH CENTURY
AGE OF THE GERMAN TITANS
……CHARITE ` BERLIN LINEAGE
Langenbeck,
Billroth, Kocher
Anesthesia 1846
Czerny,
Polya, Mikulicz, Sauerbruch
The pleasure of a physician is little, the gratitude of patients is rare
and even rarer is material reward, but, these things never deter the
student who feels the call within him"
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Bernhard Rudolf Konrad von Langenbeck (1810
– 1887):Father of surgical residency
Franko Prussian war of 1870–71
Militär-ärztliche Gesellschaft
A forum of military surgeons of all nationality
"father of the surgical residency". Berlin
a system whereby new medical graduates would live at the
hospital as they gradually assumed a greater role in the dayto-day care and supervision of surgical patients.
Among his most well-known "house staff" were such
illustrious surgeons as Billroth and Emil theodore Kocher
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…..And the great nephew of Langenbeck
Theodor Billroth (1829-1894)
First oesophagectomy in animal 1872
Adenoma carcinoma sequence 1855
First laryngectomy1874
Billroth I gasrectomy1881
Prolonged apprenticeship
Animal and cadaveric dissection
Study of surgical literature
Polya
Czerny
Mikulicz
sauerbruch
Halstead
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Theodor Kocher (1841-1917)
Vincenz Czerny (1842 – 1916)
1877,
first “surgeon” to successfully resect
a cervical oesophageal cancer
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Johann von Mikulicz-Radecki 1850-1905
Skin tube 1886
oesophagoscope
Listerism
Respiratory studies
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(Ernst) Ferdinand Sauerbruch..The Dark Lord..
German surgeon, Marburg, Zürich, München, Berlin 1875 - 1951, born in
Bremen, died in Berlin
Sauerbruchs chamber
1904
Limb prosthesis
Tuberculosis diet
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William Halstead (1852-1922) John
Hopkins.. Brings experimental surgery and
apprenticeship to America
Student of
John Dalton a pioneering experimental physiologist
Theodore billroth
1889 technique of inguinal hernia repair
early 1890s radical mastectomy for breast cancer
1892 he described ligation of the subclavian artery.
Fallen
Hero
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Early 1900s he published on autotransplantation
of the parathyroid gland..
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Story of anaesthesia
AD 220 the Chinese surgeon Hua
surgical anaesthesia.
In 1526 Paracelsus
ether (which he knew as oleum vitreoli dulce) could
quieten chickens and
relieve pain.
In Birmingham in 1772 Priestley, a Unitarian
minister, discovered nitrous oxide
1825Charles Waterton
Published wanderings in South America
accurate account of curare.
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1677 Robert hooke maintained life in dogs by
bellows
1775 John Hunter two way air flow
1846 Morton
1853 simpson
Magill & Rowbotham
1904
Sauerbruch
Negative pressure airtight chamber
1904
Brauer and Peterson
CPAP Positive pressure chamber
Endotracheal anaesthesia
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…Penicillin saga
Fleming A. On the antibacterial action of cultures of a
penicillium with special reference to their use in the
isolation ofB influenzae. BrJExp Pathol 1929;10:22636.
Chain E, Florey HW, Gardner AD, Heatley NG,
Jennings
MA, Orr-EwingJ, Sanders AG. Penicillinasa
chemotherapeutic
agent. Lancet 1940;ii:226-8.
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Franz Torek 1913
FirstTransthoracic resection
Endotracheal anaesthsia
Oesophagectomy
without reconstruction
12 year survival
Torek F. The first successful case of resection of the thoracic portion of
the esophagus for carcinoma. Surg Gynecol Obstet, 1913;16:614
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Attempts at Reconstruction
1907 Dr. Cesar Roux (famous for the Roux-Y operation)
use of jejunum as a substitute for the esophagus
1911, Kelling
fi rst successful case of cervical oesophagocolostomy usimg
transverse colon
1920, Kirschner
successful oesophago gastrostomy in the neck,
pulling up a gastric pedicle through a subcutaneous route. in a
patient who had swallowed lye and had a stricture
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Between the great wars
Ohsawa 1933
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series of resections with immediate
anastomosis‘
Over a period of seven years, in a series of 101
cases, he found 18 in which the growth involved
the lower oesophagus
or cardia and in which he was able to carry out
resection and oesophago gastric
anastomosis.
Eight of these patients survived.
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Between the great wars…..
Grey Turner 1933: prodigious writer and a lone Ranger
Transhiatal Resection
Vice-President
Royal College of Surgeons of England,
HunterianOrator and Hunterian Trustee.
President of the Association of Surgeons
United States :
Murphy Oration
Balfour Oration
Only British surgeon to be awarded the
Bigelow Medal.
GREY TURNER AND THE EVOLUTIONOF OESOPHAGEAL SURGERY
Ann. Roy. Coll. Surg. Engl. 1971, vol. 49)
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R. H. FRANKLIN F.R.!C.S.
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End of the old era and the opening of a new one.
'Finally came the great day of my long-looked-for pilgrimage to Glasgow. In
1901 my appendix had to be removed, As soon as I entered the operating theatre where
Macewen was about to start work, it seemed like a new world to me;
and I have never forgotten the tall, handsome figure standing by the basin washing his hands
with the most punctilious care. To me it seemed wonderful that in those days
someone should come in and inoculate culture media from beneath the surgeon'sthe
surgeon's
nails.
'It was not that the work in Newcastle-upon-Tyne was of a poor standard, for
I yield to no one in my esteem for Rutherford Morison. But our theatre was not a sacred place,
withoutany of the ritual associated with a surgical operation as we know it to-day, or
as Macewen knew it and practised it in those days. All our sterilisation was by
immersion in strong antiseptics, nothing was boiled and the arrangements were
of the simplest.
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Radicalism
'better todo too much than too little'
care
Better a living
problem than a dead certainty
Grey Turner 1933
successful Transhiatal
resection
Patient focus
'Gentlemen, you are probably saying to yourselves this is
only anAppendicectomy -but I can assure you that this is
the most important operation being carried out to-day-for
this particular patient.‘
decimalization and metrication.
vision
'One day they will operate on the heart-mark my words';
'We shall never overcome cancer by surgery, it will be by
something we shall inject
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Following Grey turner
& Ohsawa
1938, Adams and Phemister
lower oesophagectomy and immediate
oesophagogastrostomy through open
thoracotomy1933,Osawa at Kyoto University
First successful cases worldwide of the same procedure
Garlock 1944
Sweet1948
worldwide leaders of oesophageal surgery in the middle of the
twentieth century, succeeded in oesophago gastrostomy in the
thoracic cavity
Oshawas left thoracoabdominal technique remained a
dangerous procedure for mid oesophageal tumoursGARLOCK,
J. H. (1944) Surg. Gynec. Obstet. 78, 23.
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Status of surgical treatment for esophageal cancer worldwide, 1965
T. Kakegawa, MD · H, Fujita, Gen Thorac Cardiovasc Surg (2009) 57:55–63
Cases of resection (%)
Operative mortality (%)
Cases of 5-year survival (%)
Garlock
181 (39.6%)
31.5%
11 (21.2%)
Sweet
303 (52.1%)
17.5%
18 (12.1%)
Ellis
245 (27.0%)
15.9%
20 (17.2%)
Logan
418 (59.7%)
30.0%
57 (23.0%)
Petrov
123 (19.0%)
50.0%
7 (11.5%)
Berezov
770 (29.2%)
33.5%
Wu
152 (40.1%)
18.4%
6 (23.7%)
9.3%
32.8%
13 (6.2%)
Kuo
150 (12.7%)
Lortat-Jacob 308 (54.8%)
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…..Joining up the gullet : the War years
folowers of ohsawa and Grey Turner
1937 Nissen First successful anastomosis
reported a case of transthoracic cardio-oesophageal
resection for penetrating ulcer, and this was probably the first successful
anastomosis in Europe and the Americas.
1938 Adams and Phemister : First one stage resection
but most oesophageal surgeons continued to practise the twostage
procedure,
ADAMS, W. E., and PHEMISTER, D. B. (1938) J. thorac. Surg. 7, 621.
1942 Brock: The first follower
carried out a successful
one-stage resection and anastomosis for a patient with a large myoma.
BROCK, R. C. (1942) Brit. J. Surg. 30, 146.
1945 Vernon Thompson: First UK success
The first patient with a carcinoma to be treated successfully in this way in the UK
THOMPSON, V. C. (1945) Brit. J. Surg. 32, 377.
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Post war years
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1946, The watershed:
Transthoracic resection
• Lewis I. Hunterian lecture
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The surgical treatment of carcinoma of the oesophagus with
special reference to a new operation for growths of the
middle third.
Br J Surg, 1946;34:18
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Inspiration to be a doctor severe attack
of acute appendicitis at the age of I2-being
operated upon by David Ellis of Aberystwyth
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1939First successful pulmonary embolectomy in the UK
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Olympus: Going
Where no Camera has
Gone Before
The Pain in the Butt
Camera
Olympus
gastrocamera 1960
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Ronald Belsey
• TO Fistula
• Belsey R. Reconstruction of the esophagus with left colon. J Thorac
.
• Zenkers Diverticulum
Cardiovasc Surg 1965;49:33-55
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The American Association for Thoracic Surgery in 1966, emphasized a
dysfunction of the cricopharyngeal muscle as the underlying cause series of
45 patients, the majority of them treated with myotomy and diverticulopexy
• Antireflux procedure
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Belsey Mark IV
• Cancer
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“cure is an accident"
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1976 :Total oesophagectomy
McKeown KC. Total three stage
oesophagectomy for cancer of the
oesophagus. Br J Surg, 1976;63:259
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Poor results :
Earlam R, Cunha-Melo Jr. Oesophageal squamous cell
carcinoma. 1.
A critical review of surgery. Br J Surg, 1980;67:381
Muller JM, Erasmi H, Stelzner M, Zieren U, Pichlmaier H. Surgi
cal
Therapy of Oesophageal Carcinoma. Br J Surg, 1990;77:845
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Rt Vs Left Thoracotomy
• Launois P, Lygidakis C, Malledant G. Results of
the surgical treatment
• of carcinoma of the esophagus. Surg Gynecol
Obtet, 1983;156:753
• Similar results mortality and survival
• reflux more in left
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Total vs Subtotal
• Chasseray VM, Kiroff GK, Buard JL, Launois B. Cervical
or thoracic
• anastomosis for esophagectomy for carcinoma. Surg
Gynecol Obstet,
• 1989;169:55
• stricture more in cervical anastomosis
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Which conduit?
• Gastric
• Colon
• Greater curve tube
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Anastomosis:Staples or
handsewn
• Stricture more in stapled
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How radical is radical?
• Skinner DB, Dowlatashy KD, DeMeester TR.
• 80 patients
• radical Enbloc resection
• 9 (11%) 30 day mortality
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Potentially curablecancer of the esophagus. Cancer, 1982;50:2571
• Wong J.
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Esophageal resection for cancer: the rationale of current
practice. Am J Surg, 1987;153:18
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20 years in Chiba University
Seo and OsawaJapan surgical society
1932
Review of world literature before 1942
worldwide incidence of operative
mortality up to 1932
144 (95.4%) of the 155 patients
No sucessful reconstruction
Nakayama Japan Surgical Society 1951
incidence of operative mortality
was only 5 (16.6%) of 30 patients who
underwent subtotal
esophagectomy followed by
esophagogastrostomy
through a subcutaneous route for cancer in
the upperor middle thoracic esophagus
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Hiroshi Akiyama
1910-19.09.2012
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Three Japanese masters 1951-1966
Nakayama and Sato Chiba University : Multistage procedure
The operativemortality rate oesophagectomy
1951 16.6% of 30 patients
1966 5% of 2053 patients
Katsura at Tohoku University
8/15 55% mortality using positive pressure
0/21 0% using endotrachaeal anaesthesia
Akakura at Keio University, 1966 JATS presidential lecture :
average operative mortality rate in Japan was 15.6% ,861 of 5327
average 5-year survival rate was 12%
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Akakura keio University :
Problems to be resolved in oesophageal surgery
1. Causes of short-term mortality
1) Incorrect indication for surgery
2) Incorrect adoption of surgical procedures
3) Incorrect surgical maneuver
Postoperative complications
a. Anastomotic leakage
b. Pulmonary complication(s)
c. Circulatory failure
2. Causes of long-term mortality
1) Non-curative surgery
a. Incomplete resection of a local tumor
b. Lymph node metastasis
c. Distant organ metastasis
2) Malnutrition
3) Diseases of the elderly
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Specialisation
JSED 1965 : oesophageal Registry
5-year survival rate
1988
30.5%
1994
41.9%
10-yearsurvival rate 1994:
31.0 %
operative mortality 1994:
2% of 7539 patients
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Early
Vs
Advanced:
Lymph
Nodal spread
Recurrent
laryngeal and
paracardiac
sentinel nodes?
Kakegawa 1994
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Lymphadenectomy Recurrent laryngeal chain
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Transhiatal Resection
• Denk in 1913,
• Refined by Turner in 1931
• Popularised by Orringer 1978
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Transhiatal oesophgectomy
University of Michigan Hospitals,Ann Arbor, MI.
1.Orringer MB, Sloan H: Esophagectomy without
thoracotomy.
J Thorac Cardiovasc Surg 76:643, 1978
2. Orringer MB, Orringer JS: Esophagectomy without
thoracotomy:
a dangerous operation? J Thorac Cardiovasc Surg
85:72, 1983
3. Omnger MB: Transhiatal blunt esophagectomy
without thoracotomy.
Mark
In Cohn LH (ed): Modem Technics in Surgery:
Cardio-Thoracic Surgery. Mt. Kisco, NY, Futura, 1983, vol
62, installment 9
4. Omnger MB: Partial median sternotomy: anterior
approach
to the upper thoracic esophagus. J Thorac Cardiovasc Surg
87:124, 1984
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Orringer
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Orringer MB, Orringer JS: Esophagectomy without
thoracotomy:
a dangerous operation? J Thorac Cardiovasc Surg
85:72, 198
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Orringer MB, Orringer JS: Esophagectomy without
thoracotomy:
a dangerous operation? J Thorac Cardiovasc Surg
85:72, 198
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200 patients
AverageBlood loss
<1000 ml
Hospital mortality
6%.
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11 years of Laparoscopic
oesophageal surgery
• 1991, Dallemagne et al and Geagea
Laparoscopic fundoplication
• 1991 Shimi et al
• Laparoscopic esophageal myotomy.
• 1993, Cuschieri et al
• outcome of Laparoscopic fundoplication
• > 100 patients multicenter study
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Antoon Lerut
Student of
Ronald Belsey
James Luketich
philadelphia
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Leuven
Bristol
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Staging : Evolution in the west
• CT and EUS
• Tio TL, Cohen P, Coene PP.
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Endosonography and computed tomographyof esophageal carcinoma.
Gastroenterology, 1989;96:1478
• Grimm H, Soehendra N, Hamper K.
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Contribution of endosonographyto preoperative staging in esophageal
and stomach cancer. Chirurg,
1989;60:684 Gastroenterology, 1989;96:1478
Rankin SC, Taylor H, Cook GJ, Mason R.
Computed tomographyand positron emission tomography in the pre-operative staging of
oesophageal carcinoma. Clin Radiol, 1998;53:659
• Thoracoscopy
• Krasna MJ, Reed CE, Jaklitsch MT. Thoracoscopic staging of
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esophageal cancer: a prospective, multiinstitutional trial. Cancer and Leukemia
Group B Thoracic Surgeons. Ann Thorac Surg, 1995;60:1337
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MDT
• Ajani JA. Current status of new drugs and
multidisciplinary approaches
• in patients in patients with carcinoma of
the esophagus.
• Chest, 1998;113:112S
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Collaboration not competition
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Ando N, Iizuka T, Kakegawa T.
A randomized trial of surgery wit hand without chemotherapy for localized squamous carcinoma of
the thoracic esophagus. J Thorac Cardiovasc Surg, 1997;114:205
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Teniere P, Hay JM, Fingerhut A.
Postoperative Radiation does no t increase survival after curative resection for squamous cell
cancer ofthe middle and lower oesophagus as shown by a multicenter controlled trial. Surg
Gynecol Obstet, 1991;173:123
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Leprise E, Etienne PL, Meunier B. A randomized study of chemotherapy, radiation therapy, and
surgery versus surgery for localizedsquamous cell carcinoma of the esophagus. Cancer,
1994;73:1779
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Chemoradiation increased
survival
Walsh TN, Noonan N, Hollywood D.
A comparison of multimodaltherapy and surgery for
esophageal adenocarcinoma.
N Engl J Med 1996;335:462
Forastiere AA, Orringer MB, Perez-Tamayo C,
Urba SG, ZahurakM. Preoperative chemoradiation
followed by transhiatal esophagectomy for carcinoma of
the esophagus: final report.
J ClinOncol, 1993;11:1118
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Junctional
tumour:
Siewert Type
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Today
Minimal access
EMR
ESD
PDT
Chemoradiation
Biological therapy
Multimodality treatment
New treatments?
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Please do not walk away when you
stumble onto it…
Introduction of modern surgical techniques
should lead to a paradigm shift in the mindset of
the referring clinicians
Things do not change; we change
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