This study analyzes the respiratory complications in a retrospective study of 309 resections for esophageal cancer. We mainly performed two types of resections according to the height of the tumor: the Ivor-Lewis resection for middle thoracic lesions (182 cases), and the Akiyama resection for upper thoracic lesions (127 cases). We compared the respiratory complications occurring after these two procedures. Our overall mortality and morbidity rates were, respectively, 9% and 37%. In our series, the mortality rate was 4 times higher after the Akiyama procedure than after the Ivor-Lewis procedure, and the morbidity was twice as high. Respiratory complications accounted for 64% of the postoperative deaths. The Akiyama procedure yielded more respiratory complications, especially isolated bronchopneumonia and necrosis of the trachea or of the right or left main bronchus. Respiratory complications accounted for 53% of morbidity, mainly recurrent nerve paralysis with false passages and stasis in the transplant. Both are directly related to the surgical act and often result in bronchopneumonia. Rather than the surgical technique or the skill of the surgeon, it seems that local factors, such as the position of the tumor on the esophagus, increased the incidence of recurrent nerve paralysis following the Akiyama procedure. However, the rate of respiratory complications remained high after the Ivor-Lewis procedure. Patient history, which sometimes included a previous ENT cancer, must be taken into account, as well as the gravity of the operation and the duration of the intubation. Frequent false passages and reflux must be fought by intensive physiotherapy and, when necessary, by early tracheotomy before the patient develops postoperative acute respiratory distress syndrome.

Despite obvious improvements in operative and postoperative management after esophageal resection, surgical treatment of esophageal cancer is still disappointing in terms of long term results. The purpose of the present study was to verify these poor results statistically and to discuss the value of a modified therapeutic approach. Our experience covers 349 esophageal resections performed between 1979 and 1992. These patients were predominantly males (93%) with squamous cell carcinoma (86%). The majority of the patients underwent either an Ivor-Lewis (52%) or an Akiyama procedure (36%). Survival was estimated according to the Kaplan-Meier model. Influence of parameters such as sex, histology, type of resection and TNM-staging was assessed with the "log-rank" test. The perioperative mortality was 10%. The non-fatal morbidity rate was 34%, and was most often related to anastomotic leaks. Pathological staging disclosed a majority of T3 tumors (71%). The overall survival rate was 54% at one year, 28% at 2 years and 9% at 5 years. This survival was not influenced by either histology (squamous cell or adenocarcinoma), the type of resection (Ivor-Lewis or Akiyama procedure). A slightly superior survival rate was observed after Ivor-Lewis procedure and is explained by a lower postoperative complication rate. In particular, diffuse N2 disease (abdominal and mediastinal) had a worse prognosis than localized N2. N1 disease was probably understaged, since survival was comparable to localized N2. The natural history was characterized by development of metastases (43%) rather than by local recurrence. We conclude that these results may justify surgery for palliation of dysphagia in so far as the post-operative morbidity is reduced, as we observed with Ivor-Lewis procedures. However, improvement of long-term survival requires a multimodality oncologic approach.

Despite obvious improvements in operative and postoperative management after esophageal resection, surgical treatment of esophageal cancer is still disappointing in terms of long term results. The purpose of the present study was to verify these poor results satistically and to discuss the value of a modified therapeutic approach. Our experience covers 349 esopphageal resections performed between 1979 and 1992. These patients were predominantly males (93 %) with squamous cell carcinoma (86 %). The majority of the patients underwent either an Ivor-Lewis (52 %) or an Akiyama procedure (36 %). Survival was estimated according to the Kaplan-Meier model. Influence of parameters such as sex, histology, type of resection and TNM-staging was assessed with the << logrank >> test. The perioperative mortality was 10%. The non-fatal morbidity rate was 34%, and was most often related to anastomotic leaks. Pathological staging disclosed a majority of T3 tumors (71 %). The overall survival rate was 54 % at one year, 28 % at 2 years and 9 % at 5 years. This survival was not influenced by either histology (squamous cell or adenocarcinoma), the type of resection (Ivor-Lewis or Akiyama procedure). A slightly superior survival rate was observed after Ivor-Lewis procedure and is explained by a lower postoperative complication rate. In particular, diffuse N2 disease (abdominal and mediastinal) had a worse prognosis than localized N2. N1 disease was probably understaged, since survival was comparable to localized N2. The natural history was characterized by development of metastases (43 %) rather than by local recurrence. We conclude that these results may justifiy surgery for palliation of dysphagia in so far as the post-operative morbidity is reduced, as we observed with Ivor-Lewis procedures. However, improvement of long-term survival requires a multimodality oncologic approach.

On the basis of the retrospective study of a series of 348 pneumonectomies, the authors have attempted to assess whether the risks of postoperative complications were increased if the operation was carried out by trainee surgeons. All operations were performed for cancer, with a stapler being used for bronchial suture. The patients were classified in three groups according to the surgeon: 133 (38%) were operated by an University professor (group I, 2 surgeons), 171 (49%) by chief resident or hospital practicioner (group II, 3 surgeons) and 44 (13%) by an intern (group III, 14 surgeons). The homogeneity of the 3 groups was checked with alpha X2 test. The study dealt with the overall mortality as well as with the specific complications of pneumonia, namely empyema and bronchopleural fistulae. The overall postoperative mortality rate was similar in the 3 groups (respectively 8%, 8% and 5%), as well as the occurrence of empyema (respectively 4%, 3% and 5%). A difference that, though not significant statistically, is not negligible, appears for bronchopleural fistulae, which complicate 9% of the operations carried out by interns vs. 4% in the other 2 categories. These observations challenge a number of studies claiming that surgery performed by inexperienced surgeons is innocuous. However, pneumonectomy is an essential step in the training to thoracic surgery, so that no candidate with sufficient surgical maturity should be prevented from performing it.

On the basis of the retrospective study of a series of 348 pneumonectomies, the authors have attempted to assess whether the risks of postoperative complications were increased if the operation was carried out by trainee surgeons. All operations were performed for cancer, with a stapler being used for bronchial suture. The patients were classified in three groups according to the surgeon: 133 (38%) were operated by an University professor (group I, 2 surgeons), 171 (49%) by chief resident or hospital practitioner (group II, 3 surgeons) and 44 (13%) by an intern (group III, 14 surgeons). The homogeneity of the 3 groups was checked with alpha X2 test. The study dealt with the overall mortality as well as with the specific complications of pneumonia, namely empyema and bronchopleural fistulae. The overall postoperative mortality rate was similar in the 3 groups (respectively 8%, 8% and 5%), as well as the occurrence of empyema (respectively 4%, 3% and 5%). A difference that, though not significant statistically, is not negligible, appears for bronchopleural fistulae, which complicate 9% of the operations carried out by interns vs. 4% in the other 2 categories. These observations challenge a number of studies claiming that surgery performed by inexperienced surgeons is innocuous. However, pneumonectomy is an essential step in the training to thoracic surgery, so that no candidate with sufficient surgical maturity should be prevented from performing it.

Primary lung cancer treated by surgery may re-develop on another site. Eighteen patients were re-operated upon over a 14-year period (1970-1983) in the Thoracic Surgery Unit of Strasbourg (Prof. J. P. Witz) for a second cancerous localization. Complications and post-operative mortality were more frequent with ipsilateral excisions (8 cases) than with contralateral excisions (10 cases); this may be due to the technical difficulties associated with complementary pneumonectomy in a previously affected hemithorax. The diagnosis, usually obtained by radiography of the chest, resulted from regular, long-term surveillance of patients operated upon for lung cancer. In spite of the small number of cases in this series (1.5% of excisions for lung cancer during that period), there is no doubt that to re-operate patients with a new localization of cancer is the best therapeutic solution.

The modalities and results of surveillance of 578 patients operated upon for bronchial cancer are reported. Planned surveillance, introduced in 1981, is compared with the surveillance carried out from 1977 to 1980. The plan includes 4 radiological and clinical examinations during the 1st year, 3 during the 2nd year, 2 during the 3rd year and 1 per year thereafter. Bronchial fibroscopy is performed 9 and 18 months after surgery. In the 3rd post-operative month 10% of the patients had died, 4% had been lost sight of, and 86% had presented themselves for control examination. Regularity in attending control sessions has improved since planned surveillance was introduced: on average, the number of examinations is complied with, without modifications in the out-patient/in-patient ratio. Endoscopies are performed in 70% of the cases. Multiplying control examinations does not noticeably increases the number of pathological findings. Many relapses diagnosed on symptomatic grounds were, in fact, inaccessible to radiology and endoscopy. Five out of 19 local-regional relapses were diagnosed by fibroscopy. It is concluded that there is no need to increase the number of consultations, and that the complementary examinations performed should be more carefully selected.

A review of the world literature yielded 95 cases of leiomyosarcoma of the esophagus. Another case has been added. The symptoms of esophageal leiomyosarcoma and squamous cell carcinoma are approximately the same. This rare tumor tends to be polypoid, rarely invasive and metastatic. Surgical resection with esophagogastric anastomosis is the best treatment, with a 5-year survival rate of 27.4%.