Davydov M, Stilidi I, Bokhyan V, Arzykulov G
Surgical Department of Thoracoabdominal Oncology, Russian Cancer Research Centre, Kashirsskoe s. 24, Moscow 115478, Russia.
Eur J Cardiothorac Surg. 2001 Aug;20(2):405-8. doi: 10.1016/s1010-7940(01)00796-5.
The locally advanced esophageal carcinoma can be complicated by fistulas. According to published data, the incidence rate of malignant esophageal fistulas is about 13%. The range of treatment modalities proposed by different authors varies from palliation to active and, if possible, radical surgical interventions. In the present study, we investigated combined esophagectomies as a radical treatment of the malignant esophageal fistulas.
Thirty-five patients (aged 28--67) with malignant esophageal fistulas of different localizations were operated over a period from 1990 to 2000. The tumor was located in the upper, middle and lower thoracic esophagus in four, 20 and 11 cases, respectively. The malignant fistula with the mediastinum, pleural cavity, lungs, bronchi and trachea was observed in 21, two, five, four and three cases, respectively. Subtotal esophagectomy and esophagogastroplasty were performed in 18 patients; subtotal esophagectomy with intrapleural coloesophagoplasty was performed in one case; proximal gastric and lower thoracic esophageal resection from the left-side abdominothoracic approach was performed in three cases. Esophagogastric bypass anastomoses were formed in ten patients. Gastrostomy was performed in three patients.
The complication rate was 40% (14 out of 35); the postoperative mortality was 14.3% (five out of 35). In patients after esophageal resection, the mortality rate was 13.6% (three out of 22). With a median survival of 13 months (range, 3--31), the 2-year survival rate was 21% after combined esophagectomies.
The goal of surgery for esophageal cancer with various fistulas is to completely resect the primary tumor and involved adjacent structures with clear surgical margins and extended two-field lymphadenectomy. The importance of performing a complete resection is stressed by the absence of 1-year survivors among patients who underwent bypass surgery or gastrostomy. We consider that en-bloc combined resection of esophageal cancer complicated by fistula can be done with a low mortality.
局部晚期食管癌可并发瘘管。根据已发表的数据，恶性食管瘘的发生率约为13%。不同作者提出的治疗方式范围从姑息治疗到积极治疗，若有可能则采取根治性手术干预。在本研究中，我们调查了联合食管切除术作为恶性食管瘘的根治性治疗方法。
1990年至2000年期间，对35例（年龄28 - 67岁）不同部位的恶性食管瘘患者进行了手术。肿瘤分别位于胸段食管上段4例、中段20例、下段11例。分别有21例、2例、5例、4例和3例观察到与纵隔、胸腔、肺、支气管和气管的恶性瘘管。18例患者行次全食管切除术和食管胃成形术；1例行次全食管切除术加胸膜腔内结肠代食管成形术；3例行经左胸腹联合切口近端胃和胸段食管下段切除术。10例患者行食管胃旁路吻合术。3例患者行胃造口术。
并发症发生率为40%（35例中的14例）；术后死亡率为14.3%（35例中的5例）。食管切除术后患者的死亡率为13.6%（22例中的3例）。中位生存期为13个月（范围3 - 31个月），联合食管切除术后2年生存率为21%。
伴有各种瘘管的食管癌手术目标是完全切除原发肿瘤及受累的相邻结构，切缘清晰，并进行扩大的两野淋巴结清扫。接受旁路手术或胃造口术的患者中没有1年存活者，这强调了完整切除的重要性。我们认为，对并发瘘管的食管癌进行整块联合切除可降低死亡率。
