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DOI: 10.1055/s-2007-960674
© Georg Thieme Verlag Stuttgart · New York
Chirurgie des Ösophaguskarzinoms - Qualitätssicherung
Surgery of Esophageal Cancer - Quality ManagementPublikationsverlauf
Publikationsdatum:
22. Mai 2007 (online)
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Zusammenfassung
Das Ösophaguskarzinom ist weltweit der sechsthäufigste bekannte maligne Tumor und stellt 4 % der neu diagnostizierten Karzinome dar. Die 5-Jahres-Überlebensrate liegt zwischen 8 bis 20 %. Innerhalb von Europa und Nordamerika stieg die Inzidenz des Adenokarzinoms in den 1990ern um 100 %; eine Assoziation mit einer Refluxkrankheit und einem metaplastischen Umbau der distalen Ösophagusschleimhaut gilt als gesichert. Diagnose: In der Regel müssen aufgrund der Elastizität des Ösophagus etwa zwei Drittel des Lumens verschlossen sein, um eine Dysphagie hervorzurufen. Da die Schluckstörung das führende Symptom in 80 bis 90 % der Patienten mit Ösophaguskarzinom darstellt, ist bei jedem Erwachsenen, der unter einer Dysphagie leidet eine Ösophagoskopie mit Biopsie nahezu zwingend indiziert. Weitere derzeit obligate Umfelduntersuchungen umfassen die CT von Thorax und Abdomen zur Frage von Fernmetastasen (M-Status) einschließlich von Lymphknotenfernmetastasen am Truncus coeliacus und zervikal und die Endosonografie (EUS) zur Beurteilung der Tiefeninvasion (T-Stadium) sowie von peritumoralen Lymphknotenmetastasen (N-Status). Bei Tumoren im oberen und mittleren thorakalen Ösophagus kann neben der EUS auch die Bronchoskopie zur Frage einer Affektion des Tracheobronchialsystems indiziert sein. Die Wertigkeit des PET-CTs zur Beurteilung eines M 1-Stadiums komplementär oder als Alternative zur CT kann derzeit noch nicht abschließend beurteilt werden. Therapie: Die Therapie beinhaltet Chirurgie, Chemotherapie, Strahlentherapie oder eine Kombination dieser Verfahren. Die Therapie des Ösophaguskarzinoms wird durch die Kenntnis der Tatsache beeinflusst, dass bei den meisten Patienten eine ausgedehnte lokale Tumorinvasion eine definitive Heilung häufig, ein metastasiertes Stadium sogar gänzlich unmöglich macht. Eine Indikation zu einer palliativen Behandlung besteht, wenn der Allgemeinzustand der Patienten eine Resektion verbietet, lokaler Irresektabilität aufgrund einer Infiltration von lebensnotwendigen Strukturen oder prognostische Irresektabilität aufgrund einer Fernmetastasierung. Allenfalls 50 % der Patienten mit Ösophaguskarzinom sind bei Vorstellung noch kurativ resektabel. Um das Risiko eines endoluminalen Rezidives zu minimieren, sollten die Resektionsgrenzen in situ 6 bis 8 cm vom Tumor entfernt sein. Hinsichtlich des Zugangsweges, des Ausmaßes des Lymphadenektomie und der Höhe der Anastomose werden verschiedene Techniken der Ösophagektomie unterschieden:
- Der Zugangsweg wird unterschieden in transthorakale, transhiatale und zerviko-abdominelle Ösophagektomien.
- In Abhängigkeit vom gewählten Zugangsweg ergeben sich erhebliche Unterschiede hinsichtlich der Radikalität der Lymphknotenausräumung: Unterschieden werden die 1-Feld-Lymphadenektomie (stumpfe Dissektion) von der 2-Feld- (En-bloc-Ösophagektomie) und 3-Feld-Lymphadenektomie (En-bloc-Ösophagektomie + zervikale Neck-Dissektion).
- Hinsichtlich der Anastomosenhöhe werden kollare von intrathorakalen Anastomosen unterschieden.
Abstract
Oesophageal cancer is the sixth most common malignancy worldwide and represents 4 % of newly diagnosed cancers. 5-year survival probability is given between 8 to 20 %. Within North America and Europe, the incidence of adenocarcinoma rose 100 % in the 1990s; strongly correlated with reflux and Barrett's metaplasia. Diagnosis: Because of the elasticity of the esophagus, usually two thirds of the lumen is obstructed before dysphagia occurs. Because dysphagia is the leading complaint in 80 to 90 % of patients with esophageal carcinoma, any adult who complains of dysphagia warrants esophagoscopy and biopsy to rule out carcinoma. Further obligatory examinations include CT of chest and abdomen to assess distant metastases (M 1) including the celiac trunk and cervical lymph nodes. Endoscopic ultrasound (EUS) is applied for proper assessing the depth of tumor invasion, length of tumor regional nodal disease, and involvement of adjacent structures. The power of the PET-CT for evaluation of distant metastases complementary or as an alternative for CT is not yet clear. Therapy: Treatment includes surgery, chemotherapy, radiation, or a combination of these techniques. Therapy for esophageal carcinoma is influenced by the knowledge that alocal tumor invasion or distant metastatic disease often precludes cure. Palliation is appropriate when the general condition of the patients prohibits resection or in case both technical or prognostic irresectability due to extensive invasion of vital structures or due to distant metastases. However, 50 % of the patients with oesophageal carcinoma at the time of their presentation are eligible for curative treatment. In order to minimize the risk of endoluminal recurrence, a safe margin of 6- to 8-cm of normal esophagus has to be removed. Concerning the surgical approach, the extent of the lymphadenectomy and the level of the anastomosis, several techniques of oesophagectomy exist.
- According to the surgical approach transhiatal, thoracoabdominal and cervicoabdominal approaches are differentiated.
- Depending from the approach there are also different levels of lymphadenectomy: One-Field-Lymphadenectomy (only blunt dissection), two-field-lymphadenectomy (En-Bloc-Oesophagectomy) and three-field-lymphadenectomy (En-Bloc-Oesophagectomy + neck dissection).
- Concerning the site of anastomosis, collar vs. intrathoracic anastomosis are distinguished.
Schlüsselwörter
Ösophaguskarzinom - transthorakale - transhiatale - zerviko-abdominelle Ösophagektomie
Key words
oesophageal carcinoma - thoracoabdominal - transhiatal - cervico-abdominal oesophagectomy
Literatur
- 1 Daly J MKL, Menck H R. National Cancer Data Base report on esophageal carcinoma. Cancer. 2005; 78 1820-1828
- 2 Lagergren J, Bergstrom R, Lindgren A, Nyren O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med. 1999; 340 825-831
- 3 Skinner D B, Little A G, Ferguson M K. et al . Selection of operation for esophageal cancer based on staging. Ann Surg. 1986; 204 391-401
- 4 Lin O S, Mannava S, Hwang K L, Triadafilopoulos G. Reasons for current practices in managing Barrett's esophagus. Dis Esophagus. 2002; 15 39-45
- 5 Pfau P R, Ginsberg G G, Lew R J. et al . EUS predictors of long-term survival in esophageal carcinoma. Gastrointest Endosc. 2001; 53 463-469
- 6 Hagen J A, DeMeester S R, Peters J H. et al . Curative resection for esophageal adenocarcinoma: analysis of 100 en bloc esophagectomies. Ann Surg. 2001; 234 520-530 , ; discussion 530 - 531
- 7 Ellis Jr F H. Treatment of carcinoma of the esophagus or cardia. Mayo Clin Proc. 1989; 64 945-955
- 8 Koch J, Halvorsen Jr R A. Staging of esophageal cancer: computed tomography, magnetic resonance imaging, and endoscopic ultrasound. Semin Roentgenol. 1994; 29 364-372
- 9 Reed C E, Mishra G, Sahai A V. et al . Esophageal cancer staging: improved accuracy by endoscopic ultrasound of celiac lymph nodes. Ann Thorac Surg. 1999; 67 319-321 , discussion 322
- 10 Tio T L, Cohen P, Coene P P. et al . Endosonography and computed tomography of esophageal carcinoma. Preoperative classification compared to the new (1987) TNM system. Gastroenterology. 1989; 96 1478-1486
- 11 Vilgrain V, Mompoint D, Palazzo L. et al . Staging of esophageal carcinoma: comparison of results with endoscopic sonography and CT. AJR Am J Roentgenol. 1990; 155 277-281
- 12 Botet J F, Lightdale C J, Zauber A G. et al . Preoperative staging of esophageal cancer: comparison of endoscopic US and dynamic CT. Radiology. 1991; 181 419-425
- 13 Siewert J R, Holscher A H, Dittler H J. Preoperative staging and risk analysis in esophageal carcinoma. Hepatogastroenterology. 1990; 37 382-387
- 14 Van Dam J. Endosonographic evaluation of the patient with esophageal cancer. Chest. 1997; 112 (4 Suppl) 184 S-190 S
- 15 Ell C, May A, Gossner L. et al . Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett's esophagus. Gastroenterology. 2000; 118 670-677
- 16 Nijhawan P K, Wang K K. Endoscopic mucosal resection for lesions with endoscopic features suggestive of malignancy and high-grade dysplasia within Barrett's esophagus. Gastrointest Endosc. 2000; 52 328-332
- 17 Rice T W, Boyce G A, Sivak M V. Esophageal ultrasound and the preoperative staging of carcinoma of the esophagus. J Thorac Cardiovasc Surg. 1991; 101 536-543 , discussion 543-544
- 18 Nishimaki T, Tanaka O, Ando N. et al . Evaluation of the accuracy of preoperative staging in thoracic esophageal cancer. Ann Thorac Surg. 1999; 68 2059-2064
- 19 Brugge W R, Lee M J, Carey R W, Mathisen D J. Endoscopic ultrasound staging criteria for esophageal cancer. Gastrointest Endosc. 1997; 45 147-152
- 20 Penman I D, Williams D B, Sahai A V. et al . Ability of EUS with fine-needle aspiration to document nodal staging and response to neoadjuvant chemoradiotherapy in locally advanced esophageal cancer: a case report. Gastrointest Endosc. 1999; 49 783-786
- 21 Luketich J D, Schauer P R, Meltzer C C. et al . Role of positron emission tomography in staging esophageal cancer. Ann Thorac Surg. 1997; 64 765-769
- 22 Ott K, Weber W, Siewert J R. The importance of PET in the diagnosis and response evaluation of esophageal cancer. Dis Esophagus. 2006; 19 433-442
- 23 Wren S M, Stijns P, Srinivas S. Positron emission tomography in the initial staging of esophageal cancer. Arch Surg. 2002; 137 1001-1006; , discussion 1006-1007
- 24 Kinkel K, Lu Y, Both M. et al . Detection of hepatic metastases from cancers of the gastrointestinal tract by using noninvasive imaging methods (US, CT, MR imaging, PET): a meta-analysis. Radiology. 2002; 224 748-756
- 25 Krasna M J, McLaughlin J S. Thoracoscopic lymph node staging for esophageal cancer. Ann Thorac Surg. 1993; 56 671-674
- 26 Krasna M J, Reed C E, Jaklitsch M T. et al . Thoracoscopic staging of esophageal cancer: a prospective, multiinstitutional trial. Cancer and Leukemia Group B Thoracic Surgeons. Ann Thorac Surg. 1995; 60 1337-1340
- 27 Nishimura H, Tanigawa N, Hiramatsu M. et al . Preoperative esophageal cancer staging: magnetic resonance imaging of lymph node with ferumoxtran-10, an ultrasmall superparamagnetic iron oxide. J Am Coll Surg. 2006; 202 604-611
- 28 Patel A N, Buenaventura P O. Current staging of esophageal carcinoma. Surg Clin North Am. 2005; 85 555-567
- 29 Krasna M J, Reed C E, Nedzwiecki D. et al . CALGB 9380: a prospective trial of the feasibility of thoracoscopy / laparoscopy in staging esophageal cancer. Ann Thorac Surg. 2001; 71 1073-1079
- 30 Krasna M J. The role of thoracoscopic lymph node staging in esophageal cancer. Int Surg. 1997; 82 7-11
- 31 Meunier B, Spiliopoulos Y, Stasik C. et al . Retrosternal bypass operation for unresectable squamous cell cancer of the esophagus. Ann Thorac Surg. 1996; 62 373-377
- 32 Conlan A A, Nicolaou N, Hammond C A. et al . Retrosternal gastric bypass for inoperable esophageal cancer: a report of 71 patients. Ann Thorac Surg. 1983; 36 396-401
- 33 Saidi F, Abbassi A, Shadmehr M B, Khoshnevis-Asl G. Endothoracic endoesophageal pull-through operation. A new approach to cancers of the esophagus and proximal stomach. J Thorac Cardiovasc Surg. 1991; 102 43-49 , ; discussion 49-50
- 34 Orringer M B, Forastiere A A, Perez-Tamayo C. et al . Chemotherapy and radiation therapy before transhiatal esophagectomy for esophageal carcinoma. Ann Thorac Surg. 1990; 49 348-354 , , discussion 354-355
- 35 Ellis Jr F H. Standard resection for cancer of the esophagus and cardia. Surg Oncol Clin N Am. 1999; 8 279-294
- 36 Lehnert T. Multimodal therapy for squamous carcinoma of the oesophagus. Br J Surg. 1999; 86 727-739
- 37 Hulscher J B, Tijssen J G, Obertop H, van Lanschot J J. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg. 2001; 72 306-313
- 38 Goldfaden D, Orringer M B, Appelman H D, Kalish R. Adenocarcinoma of the distal esophagus and gastric cardia. Comparison of results of transhiatal esophagectomy and thoracoabdominal esophagogastrectomy. J Thorac Cardiovasc Surg. 1986; 91 242-247
- 39 Zwischenberger J B, Sankar A B. Transhiatal esophagectomy. Chest Surg Clin N Am. 1995; 5 527-542
- 40 Millikan K W, Silverstein J, Hart V. et al . A 15-year review of esophagectomy for carcinoma of the esophagus and cardia. Arch Surg. 1995; 130 617-624
- 41 Pac M, Basoglu A, Kocak H. et al . Transhiatal versus transthoracic esophagectomy for esophageal cancer. J Thorac Cardiovasc Surg. 1993; 106 205-209
- 42 Orringer M B, Marshall B, Iannettoni M D. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg. 1999; 230 392-400; , discussion 400-403
- 43 Orringer M B, Marshall B, Iannettoni M D. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg. 2000; 119 277-288
- 44 Orringer M B, Marshall B, Iannettoni M D. Transhiatal esophagectomy for treatment of benign and malignant esophageal disease. World J Surg. 2001; 25 196-203
- 45 Bousamra 2nd M, Haasler G B, Parviz M. A decade of experience with transthoracic and transhiatal esophagectomy. Am J Surg. 2002; 183 162-167
- 46 Fok M, Law S Y, Wong J. Operable esophageal carcinoma: current results from Hong Kong. World J Surg. 1994; 18 355-360
- 47 McCrory C, Diviney D, Moriarty J. et al . Comparison between repeat bolus intrathecal morphine and an epidurally delivered bupivacaine and fentanyl combination in the management of post-thoracotomy pain with or without cyclooxygenase inhibition. J Cardiothorac Vasc Anesth. 2002; 16 607-611
- 48 Ellis Jr F H, Crozier R E, Gibb S P. Reoperative achalasia surgery. J Thorac Cardiovasc Surg. 1986; 92 859-865
- 49 Clouse R E, Lustman P J. Psychiatric illness and contraction abnormalities of the esophagus. N Engl J Med. 1983; 309 1337-1342
- 50 Altorki N, Skinner D. Should en bloc esophagectomy be the standard of care for esophageal carcinoma?. Ann Surg. 2001; 234 581-587
- 51 Schroder W, Gutschow C A, Holscher A H. Limited resection for early esophageal cancer?. Langenbecks Arch Surg. 2003; 388 88-94
- 52 Horgan S, Hudda K, Eubanks T. et al . Does botulinum toxin injection make esophagomyotomy a more difficult operation?. Surg Endosc. 1999; 13 576-579
- 53 Lawrence D R, Ohri S K, Moxon R E. et al . Primary esophageal repair for Boerhaave's syndrome. Ann Thorac Surg. 1999; 67 818-820
- 54 Ikeda Y, Tobari S, Niimi M. et al . Reliable cervical anastomosis through the retrosternal route with stepwise gastric tube. J Thorac Cardiovasc Surg. 2003; 125 1306-1312
- 55 Davis P A, Law S, Wong J. Colonic interposition after esophagectomy for cancer. Arch Surg. 2003; 138 303-308
Prof. Dr. J. R. Izbicki
Abteilung für Allgemein-, Viszeral- und Thoraxchirurgie · Universitäts-Krankenhaus Hamburg-Eppendorf
Martinistraße 52
20246 Hamburg
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eMail: izbicki@uke.uni-hamburg.de