The indication, efficacy, and extent of extended lymphadenectomy for a carcinoma in the thoracic esophagus remain controversial and under clinical investigation. Here we report the frequency and mode of lymph node metastasis at operation and of lymph node recurrence after operation in 70 patients who underwent three-field dissection and 75.7% of whom suffered from metastasis or recurrence in the lymph nodes (metastasis in 71.4% and recurrence in 21.4%). Metastasis or recurrence in the cervical and cervicothoracic nodes were found in 18.6% and 41.4%, respectively. The frequency of cervical and cervicothoracic lymph node metastasis or recurrence was, respectively, 40.0% and 90.0% for a carcinoma in the upper thoracic esophagus, 21.6% and 37.8% for a carcinoma in the middle thoracic esophagus, and 4.3% and 26.1% for a carcinoma in the lower thoracic esophagus. Lymph node metastasis at operation was most frequently found in the right recurrent nerve nodes, right paracardiac nodes, periesophageal nodes, and lesser curvature nodes, whereas lymph node recurrence after operation was found in the left upper recurrent nerve nodes and the right supraclavicular, celiac, and abdominal paraaortic nodes. Metastasis or recurrence was rarely found in the internal jugular, pretracheal, greater curvature, common hepatic, or splenic nodes. This finding suggests the need for recurrent nerve node dissection for all cases and for three-field dissection for a carcinoma in the upper or middle thoracic esophagus.

Carcinoma, Squamous Cell↗

PubMedDate not supplied

Evaluation of two training programs for laparoscopic cholecystectomy: incidence of major complications.

To determine the need for a training program for laparoscopic cholecystectomy, we evaluated two programs by surveying perioperative complications. The two programs were completed by eight surgeons in each. Program A consisted of 10 supervised operations and program B of only 2. A total of 1054 operations were performed, and 12 major complications required conversion to open surgery owing to transection of the bile duct in 5 cases, laceration of the common bile duct in 1 case, delayed perforation of the common hepatic duct in 1 case, bile leakage in 2 cases, duodenal injury in 1 case, and bleeding from the cystic artery in 2 cases. The incidence of a major complication was significantly higher in group B than in group A, and six of the nine major complications in group B occurred during the initial seven independent operations. Overall, the most common major complication was an injury during the operation to the common bile duct or to the hepatic duct. Four of the five transections of the bile duct required Roux-en-Y hepaticojejunostomy, and the other required end-to-end anastomosis with T-tube drainage; one laceration required simple suture closure; and the one delayed perforation required T-tube drainage. The mean duration of hospitalization for 7 patients with an injury to the bile duct was 74.4 days (range 16-151 days). We recommend that a training program for laparoscopic cholecystectomy should include at least 10 operations to prevent a major complication during the initial 10 operations.

Adolescent↗

PubMedDate not supplied

Accuracy of intraoperative ultrasonography in diagnosing liver metastasis from colorectal cancer: evaluation with postoperative follow-up results.

The accuracy of intraoperative ultrasonography in diagnosing liver metastasis was evaluated at the time of surgery and at follow-up in 189 patients with colorectal cancers. Evaluation at the time of operation revealed that the sensitivity of intraoperative ultrasonography (93.3%) was significantly (p less than 0.0001) higher than that of preoperative ultrasonography (41.3%), conventional computed tomography (47.1%), and surgical exploration (66.3%). Twenty-two of 104 metastatic liver tumors were detected solely by intraoperative ultrasonography in 18 patients (9.5% of total patients). These 22 tumors were small in size (4 x 4 mm to 15 x 18 mm) and nonpalpable during operation. During the postoperative follow-up period of 18 months or more (mean 35.6 months, median 37.1 months) after colorectal surgery, liver metastases that were unrecognized during surgery appeared in 13 (6.9%) patients. Re-evaluation based on these follow-up results indicated that the sensitivity of intraoperative ultrasonography decreased to 82.3%, which was still significantly (p less than 0.0005) better than that of other methods. Intraoperative ultrasonography was capable of identifying 18 of 31 (58.1%) patients in whom liver metastases were otherwise unrecognized at the time of operation. Intraoperative ultrasonography is more accurate in diagnosing liver metastasis than traditional screening methods, and may have a beneficial impact on the management of colorectal cancer.

Colorectal Neoplasms↗

PubMedDate not supplied

Endosonography for preoperative staging of specific nodal groups associated with esophageal cancer.

The results of endoscopic ultrasonography (EUS), used preoperatively in 74 endoscopically evaluable patients, were compared with the histopathology after subsequent total esophagectomy with radical lymphadenectomy involving a three-field dissection of the lower cervical, mediastinal, and abdominal nodes. Patients with obstruction to endoscopy were excluded from this study. Overall accuracy, specificity, and sensitivity were 87%, 90%, and 37%, respectively. EUS has an accuracy of more than 80% for detecting metastatic nodes in the cervical paraesophageal, supraclavicular, right recurrent laryngeal, left paratracheal, upper and lower paraesophageal, infraaortic, infracarinal, and lower posterior mediastinal regions. Its sensitivity is highest for cervical and upper thoracic paraesophageal, infracarinal, left paratracheal, and recurrent laryngeal nodes. Accuracy is maximum for periesophageal nodes and varies inversely with the axial distance of the nodes from the esophageal axis. We recommend that EUS be used routinely for preoperative assessment of the cervical and mediastinal nodal status.

Esophageal Neoplasms↗