Re: Esophagus Removal Mortality

[Guest guest]

n,

Thank you for digging up the two abstracts on Esophagectomies, the first being Achalasia specific. Along with the others who have posted here about the mortality rates, those of us facing E'ectomies clearly understand that since we are otherwise healthy our odds for success should naturally be better than the overall average.

This is why it seems strange to me that when Dr. Altorki (the thoracic surgeon) was "selling" me on the surgery, he quoted me a number of 5% mortality for the operation knowing full well that I am not one of his cancer patients. Why then, did he not say, that the mortality was 1% for healthy achalasia patients. Doesn't make sense. Maybe there is some kind of law or code of ethics here stating that when you tell a patient the mortality stats you must tell them the hospital average, or national average, and you're not permitted to give better statistics if the patient does not fit the usual profile (cancer). Just a thought. Maybe I'll ask my daughter that question.

He did give me a leak rate of 10% precisely matching the number you quoted in the abstract (below).

n, it appears to me that this operation is no walk in the park. It is full of places for things to go wrong, that get hidden from view, such as

"Major complications included anastomotic leak (10%), recurrent laryngeal nerve injury (5%), delayed mediastinal bleeding requiring thoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths (2%) from respiratory insufficiency and sepsis."

And then to top it off

"nearly 50% have required an anastomotic dilatation."

Excuse me for a sec, its time that I googled.

(15 minutes later)

I have to confess, I'm having trouble nailing down exactly what it means. Here is a link for anyone with more patience than I have at the moment.

Anastomotic Complications after Esophagectomy - Karger Publishers

Whatever it is, its not good and its at 50%.

If I must have the surgery and there is no reliable alternative, then I am not feeling too good at the moment as to what is in store for me.

I did not see a mention either of acid reflux, considering what is going to be done with our poor stomachs.

Clearly a lot of thought must be given in order to make a decision that we can go forward with.

Good, bad, or otherwise, whoever brings to this Board additional information on esophagectomies, I thank you. I thank you for providing me and everyone else facing this with an additional information giving us a better perspective. Many of the articles also contain extensive bibliographies providing even more information.

In a message dated 8/3/2006 8:37:14 P.M. Eastern Standard Time, rnbriely@... writes:

Here are two abstracts on esophagectomies. The first is Achalasia specific, the second is more general. Mortality rates were 2% (n=93patients) and 4% (n=1085 patients) respecitvely. Perhaps another good number to focus on is the 95% of patients in the first study who are eating well after the surgery. Best wishes to all of you having to make this difficult decision. Regards, n Abstract #1Esophagectomy for achalasia: patient selection and clinical experiencePresented at the Thirty-seventh Annual Meeting of The Society ofThoracic Surgeons, New Orleans, LA, Jan 29–31, 2001. J. Devaney MDa, Mark D. Iannettoni MDa, Mark B. OrringerMDCorresponding Author Contact Information, E-mail The CorrespondingAuthor, a and Becky Marshallaa Section of Thoracic Surgery, Department of Surgery, University ofMichigan Medical Center, Ann Arbor, Michigan, USAAbstractBackground. In 1989, we predicted an increasing number ofesophagectomies for megaesophagus and for recurrent symptoms afterprior esophagomyotomy or balloon dilatation for achalasia. Patientselection in this group is challenging, as the potential operativemorbidity of an esophagectomy must be weighed against the expectedclinical outcome after a redo esophagomyotomy or alternativeprocedures designed to salvage the native esophagus.Methods. The hospital records of 93 patients undergoing esophagectomyfor achalasia during the past 20 years were reviewed retrospectivelyand the results of operation assessed using our prospectivelyestablished Esophageal Resection Database and follow-up informationobtained through personal contact with the patients.Results. Patient age averaged 51 years. Indications for esophagectomyincluded tortuous megaesophagus (64%), failure of prior myotomy (63%),and associated reflux stricture (7%). Ninety-four percent of thepatients underwent a transhiatal esophagectomy. Stomach was used asthe esophageal substitute in 91% cases. Intraoperative blood lossaveraged 672 mL. Postoperative length of stay averaged 12.5 days.Major complications included anastomotic leak (10%), recurrentlaryngeal nerve injury (5%), delayed mediastinal bleeding requiringthoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths(2%) from respiratory insufficiency and sepsis. Follow-up has averaged38 months. In all, 95% of patients eat well; nearly 50% have requiredan anastomotic dilatation; troublesome regurgitation has been rare;and 4% have refractory postvagotomy dumping.Conclusions. Esophagectomy, preferably through a transhiatal approach,is generally safe and effective therapy in selected patients withachalasia. Unique technical considerations include difficultyencircling the dilated cervical esophagus, deviation of the esophagusinto the right chest, large aortic esophageal arteries, and adherenceof the exposed esophageal submucosa to the adjacent aorta after priormyotomy. Abstract #2Transhiatal esophagectomy for treatment of benign and malignantesophageal diseaseOrringer, M B; Marshall, B; Iannettoni, M DSection of General Thoracic Surgery, Department of Surgery, Universityof Michigan Medical Center, 2120 Taubman Health Care Center, 1500 E.Medical Center Drive, Box 0344, Ann Arbor, Michigan 48109, USA; e-mailmorrinumich (DOT) eduAbstractSince our initial 1978 report, we have performed transhiatalesophagectomy (THE) in 1085 patients with intrathoracic esophagealdisease: 285 (26%) benign lesions and 800 (74%) malignant lesions(4.5% upper, 22% middle, and 73.5% lower third/cardia). THE waspossible in 97% of patients in whom it was attempted; reconstructionwas performed at the same operation in all but six patients. Theesophageal substitute was positioned in the original esophageal bed in98%, stomach being used in 782 patients (96%) and colon in those witha prior gastric resection. Hospital mortality was 4%, with threedeaths due to uncontrollable intraoperative hemorrhage. Majorcomplications included anastomotic leak (13%), atelectasis/pneumoniaprolonging hospitalization (2%), recurrent laryngeal nerve paralysis,chylothorax, and tracheal laceration (< 1% each). There were fivereoperations for mediastinal bleeding within 24 hours of THE.Intraoperative blood loss averaged 689 ml. Altogether, 78% of thepatients had no postoperative complications. Actuarial survival of thecancer patients mirrors that reported after transthoracicesophagectomy. Late functional results are good or excellent in 80%.Approximately 50% have required one or more anastomotic dilatations.With intensive preadmission pulmonary and physical conditioning, useof a side-to-side staple technique (which has reduced the cervicalesophagogastric anastomotic leak rate to less than 3%), andpostoperative epidural anesthesia, the need for an intensive care unitstay has been eliminated and the length of hospital stay was reducedto 7 days. We concluded that THE can be achieved in most patientsrequiring esophageal resection for benign and malignant disease andwith greater safety and less morbidity than the traditionaltransthoracic approaches.

[Guest guest]

Thanks ,

I feel like I'm learning about a whole new branch of medicine that I hope nobody else, post Myotomy, will have to face. Thank you for converting some of the terms into what a newbie such as myself can understand.

In a message dated 8/3/2006 11:22:06 P.M. Eastern Standard Time, 1x2y3z@... writes:

I like www.onelook.com for definitions. Just enter a word once, and it finds definitions in all kinds of dictionaries including medical dictionaries.I found this: "An anastomosis is a surgical connection between two structures. It most commonly refers to a connection which is created between tubular structures, such as blood vessels or loops of intestine. For example, when a segment of intestine is surgically removed, the two remaining ends are sewn or stapled together (anastomosed), and the procedure is referred to as an intestinal anastomosis."The article you mentioned includes this sentence: "The majority of surgeons do prefer to use stomach to restore continuity because of the relative simplicity of the operation and the need for only one anastomosis." In other words, there's only one new connection (stomach to upper esophagus) rather than two (one at each end of a piece of colon).And this: "Dilatation of a leaking anastomosis may favorably influence healing because relative narrowing by local inflammation and spasm may contribute to obstruction ... and adversely affect spontaneous closure." in PA----- Original Message ----- From: <cynmark24aol><snip>"nearly 50% have required an anastomotic dilatation."Excuse me for a sec, its time that I googled.(15 minutes later)I have to confess, I'm having trouble nailing down exactly what it means.Here is a link for anyone with more patience than I have at the moment._Anastomotic Complications after Esophagectomy - Karger Publishers_(http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowFulltext & ProduktNr=223996 & Ausgabe=227627 & ArtikelNr=52018#SA2)

[Guest guest]

Hi ,

Your response, as well as in Pa., is helping to bring me more "up to speed," and will enable me to ask far more probing questions when I speak with the next surgeon. Thanks.

In a message dated 8/3/2006 11:03:54 P.M. Eastern Standard Time, tracylb@... writes:

,

In response to your question as to what “anastomotic dilatation†is – it is a dilatation at the connection area where they hook up your stomach to wherever your esophagus removal point is. Dr. s in Rochester, NY mentioned this to me as well as a possibility. Basically it’s typically a result of too much scar tissue forming. He indicated that the dilatation is very easy compared to what we go through now with dilatations, and usually the people that need them tend to need one or two and then that’s it. He did not give me a percentage of how many he sees, but did not see it as a major side effect or risk.

Not to trivialize any of this, but needing one or more anastomotic dilatations is the least of our worries if we go through with this surgery.

in NY

From: achalasia [mailto:achalasia ] On Behalf Of cynmark24aolSent: Thursday, August 03, 2006 9:36 PMachalasia Subject: Re: Re: Esophagus Removal Mortality

n,

Thank you for digging up the two abstracts on Esophagectomies, the first being Achalasia specific. Along with the others who have posted here about the mortality rates, those of us facing E'ectomies clearly understand that since we are otherwise healthy our odds for success should naturally be better than the overall average.

This is why it seems strange to me that when Dr. Altorki (the thoracic surgeon) was "selling" me on the surgery, he quoted me a number of 5% mortality for the operation knowing full well that I am not one of his cancer patients. Why then, did he not say, that the mortality was 1% for healthy achalasia patients. Doesn't make sense. Maybe there is some kind of law or code of ethics here stating that when you tell a patient the mortality stats you must tell them the hospital average, or national average, and you're not permitted to give better statistics if the patient does not fit the usual profile (cancer). Just a thought. Maybe I'll ask my daughter that question.

He did give me a leak rate of 10% precisely matching the number you quoted in the abstract (below).

n, it appears to me that this operation is no walk in the park. It is full of places for things to go wrong, that get hidden from view, such as

"Major complications included anastomotic leak (10%), recurrent laryngeal nerve injury (5%), delayed mediastinal bleeding requiring thoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths (2%) from respiratory insufficiency and sepsis."

And then to top it off

"nearly 50% have required an anastomotic dilatation."

Excuse me for a sec, its time that I googled.

(15 minutes later)

I have to confess, I'm having trouble nailing down exactly what it means. Here is a link for anyone with more patience than I have at the moment.

Anastomotic Complications after Esophagectomy - Karger Publishers

Whatever it is, its not good and its at 50%.

If I must have the surgery and there is no reliable alternative, then I am not feeling too good at the moment as to what is in store for me.

I did not see a mention either of acid reflux, considering what is going to be done with our poor stomachs.

Clearly a lot of thought must be given in order to make a decision that we can go forward with.

Good, bad, or otherwise, whoever brings to this Board additional information on esophagectomies, I thank you. I thank you for providing me and everyone else facing this with an additional information giving us a better perspective. Many of the articles also contain extensive bibliographies providing even more information.

In a message dated 8/3/2006 8:37:14 P.M. Eastern Standard Time, rnbrielysbcglobal (DOT) net writes:

Here are two abstracts on esophagectomies. The first is Achalasia specific, the second is more general. Mortality rates were 2% (n=93patients) and 4% (n=1085 patients) respecitvely. Perhaps another good number to focus on is the 95% of patients in the first study who are eating well after the surgery. Best wishes to all of you having to make this difficult decision. Regards, n Abstract #1Esophagectomy for achalasia: patient selection and clinical experiencePresented at the Thirty-seventh Annual Meeting of The Society ofThoracic Surgeons, New Orleans, LA, Jan 29–31, 2001. J. Devaney MDa, Mark D. Iannettoni MDa, Mark B. OrringerMDCorresponding Author Contact Information, E-mail The CorrespondingAuthor, a and Becky Marshallaa Section of Thoracic Surgery, Department of Surgery, University ofMichigan Medical Center, Ann Arbor, Michigan, USAAbstractBackground. In 1989, we predicted an increasing number ofesophagectomies for megaesophagus and for recurrent symptoms afterprior esophagomyotomy or balloon dilatation for achalasia. Patientselection in this group is challenging, as the potential operativemorbidity of an esophagectomy must be weighed against the expectedclinical outcome after a redo esophagomyotomy or alternativeprocedures designed to salvage the native esophagus.Methods. The hospital records of 93 patients undergoing esophagectomyfor achalasia during the past 20 years were reviewed retrospectivelyand the results of operation assessed using our prospectivelyestablished Esophageal Resection Database and follow-up informationobtained through personal contact with the patients.Results. Patient age averaged 51 years. Indications for esophagectomyincluded tortuous megaesophagus (64%), failure of prior myotomy (63%),and associated reflux stricture (7%). Ninety-four percent of thepatients underwent a transhiatal esophagectomy. Stomach was used asthe esophageal substitute in 91% cases. Intraoperative blood lossaveraged 672 mL. Postoperative length of stay averaged 12.5 days.Major complications included anastomotic leak (10%), recurrentlaryngeal nerve injury (5%), delayed mediastinal bleeding requiringthoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths(2%) from respiratory insufficiency and sepsis. Follow-up has averaged38 months. In all, 95% of patients eat well; nearly 50% have requiredan anastomotic dilatation; troublesome regurgitation has been rare;and 4% have refractory postvagotomy dumping.Conclusions. Esophagectomy, preferably through a transhiatal approach,is generally safe and effective therapy in selected patients withachalasia. Unique technical considerations include difficultyencircling the dilated cervical esophagus, deviation of the esophagusinto the right chest, large aortic esophageal arteries, and adherenceof the exposed esophageal submucosa to the adjacent aorta after priormyotomy. Abstract #2Transhiatal esophagectomy for treatment of benign and malignantesophageal diseaseOrringer, M B; Marshall, B; Iannettoni, M DSection of General Thoracic Surgery, Department of Surgery, Universityof Michigan Medical Center, 2120 Taubman Health Care Center, 1500 E.Medical Center Drive, Box 0344, Ann Arbor, Michigan 48109, USA; e-mailmorrinumich (DOT) eduAbstractSince our initial 1978 report, we have performed transhiatalesophagectomy (THE) in 1085 patients with intrathoracic esophagealdisease: 285 (26%) benign lesions and 800 (74%) malignant lesions(4.5% upper, 22% middle, and 73.5% lower third/cardia). THE waspossible in 97% of patients in whom it was attempted; reconstructionwas performed at the same operation in all but six patients. Theesophageal substitute was positioned in the original esophageal bed in98%, stomach being used in 782 patients (96%) and colon in those witha prior gastric resection. Hospital mortality was 4%, with threedeaths due to uncontrollable intraoperative hemorrhage. Majorcomplications included anastomotic leak (13%), atelectasis/pneumoniaprolonging hospitalization (2%), recurrent laryngeal nerve paralysis,chylothorax, and tracheal laceration (< 1% each). There were fivereoperations for mediastinal bleeding within 24 hours of THE.Intraoperative blood loss averaged 689 ml. Altogether, 78% of thepatients had no postoperative complications. Actuarial survival of thecancer patients mirrors that reported after transthoracicesophagectomy. Late functional results are good or excellent in 80%.Approximately 50% have required one or more anastomotic dilatations.With intensive preadmission pulmonary and physical conditioning, useof a side-to-side staple technique (which has reduced the cervicalesophagogastric anastomotic leak rate to less than 3%), andpostoperative epidural anesthesia, the need for an intensive care unitstay has been eliminated and the length of hospital stay was reducedto 7 days. We concluded that THE can be achieved in most patientsrequiring esophageal resection for benign and malignant disease andwith greater safety and less morbidity than the traditionaltransthoracic approaches.

[Guest guest]

Hi Everyone,

Sandy, you are very logical about this issue. This is good. If

a patient really wants to check into the mortality rate regarding

esophagectomy, the best thing to do is research the surgeon who will perform

your surgery. There are ways to do this. Mortality is contingent on

many factors, most of which Sandy

has already mentioned. Another potential complication of this procedure

is graft failure. However, this is rare and mostly occurs in patients whose

health is already compromised due to heart disease, diabetes, circulatory

problems, etc.

Z.

From: achalasia [mailto:achalasia ] On Behalf Of toomuchclutter

Sent: Wednesday, August 02, 2006

6:28 PM

achalasia

Subject: Esophagus

Removal Mortality

I wouldn't jump to the

conclusion that the mortality rate for us is similar to surgery on a cancer

patient.

I don't have the statistics

or anything, but logically, the surgery may be similar but the basic condition

of the patient could be hugely different between a cancer patient and us.

Many cancer patients have

immune issues and infection is probably a much higher risk with them than

us. A cancer patient's medical condition is much more fragile than most

of us so I wouldn't get overwhelmed by that statistic. I frankly, haven't

heard it before... and I would really question what the time frame is for

mortality. Esophageal cancer is very serious, possibly by the time a

patient resorts to surgery, they are close to the end anyway. Could be

they would have passed on regardless of the surgery.

When I was in my surgeon's

waiting room I (repeat story here) overheard an elderly gentleman asking Dr.

Fuller exactly what kind of surgery he had. Dr. Fuller answered, as he

was walking the patient out of the room, that he had removed his

esophagus. The man replied something like, oh yea, now I remember.

Sooooooo must not have been a huge ordeal, or more likely the man was in la la

land anyway and not aware. He looked alert and was alone as far as I

could tell so he must have been driving himself home. (So Cal has very limited

public transportation.) I don't know if it was for cancer or

Barrett's or other issues, but that man wasn't suffering outwardly.

Don't freak out about

statistics and mortality rates, they can be very misleading. Top

hospitals that are really the gold standard for treatment may have higher mortality

rates because they take the sickest of the sick. These things are hard to

measure. What may be a complicated surgery for one surgeon may be common

for another.

Sandy in So Cal...

actually going out to eat in public at a place where the waitresses ride roller

skates all over the restaurant. And dance, kind of a cross between Hard

Rock Cafe, and an indoor car hop and karaoke bar. Kid friendly.

It's close and reasonably priced.

[Guest guest]

Here are two abstracts on esophagectomies. The first is Achalasia

specific, the second is more general. Mortality rates were 2% (n=93

patients) and 4% (n=1085 patients) respecitvely. Perhaps another good

number to focus on is the 95% of patients in the first study who are

eating well after the surgery.

Best wishes to all of you having to make this difficult decision.

Regards,

n

Abstract #1

Esophagectomy for achalasia: patient selection and clinical experience

Presented at the Thirty-seventh Annual Meeting of The Society of

Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.

J. Devaney MDa, Mark D. Iannettoni MDa, Mark B. Orringer

MDCorresponding Author Contact Information, E-mail The Corresponding

Author, a and Becky Marshalla

a Section of Thoracic Surgery, Department of Surgery, University of

Michigan Medical Center, Ann Arbor, Michigan, USA

Abstract

Background. In 1989, we predicted an increasing number of

esophagectomies for megaesophagus and for recurrent symptoms after

prior esophagomyotomy or balloon dilatation for achalasia. Patient

selection in this group is challenging, as the potential operative

morbidity of an esophagectomy must be weighed against the expected

clinical outcome after a redo esophagomyotomy or alternative

procedures designed to salvage the native esophagus.

Methods. The hospital records of 93 patients undergoing esophagectomy

for achalasia during the past 20 years were reviewed retrospectively

and the results of operation assessed using our prospectively

established Esophageal Resection Database and follow-up information

obtained through personal contact with the patients.

Results. Patient age averaged 51 years. Indications for esophagectomy

included tortuous megaesophagus (64%), failure of prior myotomy (63%),

and associated reflux stricture (7%). Ninety-four percent of the

patients underwent a transhiatal esophagectomy. Stomach was used as

the esophageal substitute in 91% cases. Intraoperative blood loss

averaged 672 mL. Postoperative length of stay averaged 12.5 days.

Major complications included anastomotic leak (10%), recurrent

laryngeal nerve injury (5%), delayed mediastinal bleeding requiring

thoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths

(2%) from respiratory insufficiency and sepsis. Follow-up has averaged

38 months. In all, 95% of patients eat well; nearly 50% have required

an anastomotic dilatation; troublesome regurgitation has been rare;

and 4% have refractory postvagotomy dumping.

Conclusions. Esophagectomy, preferably through a transhiatal approach,

is generally safe and effective therapy in selected patients with

achalasia. Unique technical considerations include difficulty

encircling the dilated cervical esophagus, deviation of the esophagus

into the right chest, large aortic esophageal arteries, and adherence

of the exposed esophageal submucosa to the adjacent aorta after prior

myotomy.

Abstract #2

Transhiatal esophagectomy for treatment of benign and malignant

esophageal disease

Orringer, M B; Marshall, B; Iannettoni, M D

Section of General Thoracic Surgery, Department of Surgery, University

of Michigan Medical Center, 2120 Taubman Health Care Center, 1500 E.

Medical Center Drive, Box 0344, Ann Arbor, Michigan 48109, USA; e-mail

morrin@...

Abstract

Since our initial 1978 report, we have performed transhiatal

esophagectomy (THE) in 1085 patients with intrathoracic esophageal

disease: 285 (26%) benign lesions and 800 (74%) malignant lesions

(4.5% upper, 22% middle, and 73.5% lower third/cardia). THE was

possible in 97% of patients in whom it was attempted; reconstruction

was performed at the same operation in all but six patients. The

esophageal substitute was positioned in the original esophageal bed in

98%, stomach being used in 782 patients (96%) and colon in those with

a prior gastric resection. Hospital mortality was 4%, with three

deaths due to uncontrollable intraoperative hemorrhage. Major

complications included anastomotic leak (13%), atelectasis/pneumonia

prolonging hospitalization (2%), recurrent laryngeal nerve paralysis,

chylothorax, and tracheal laceration (< 1% each). There were five

reoperations for mediastinal bleeding within 24 hours of THE.

Intraoperative blood loss averaged 689 ml. Altogether, 78% of the

patients had no postoperative complications. Actuarial survival of the

cancer patients mirrors that reported after transthoracic

esophagectomy. Late functional results are good or excellent in 80%.

Approximately 50% have required one or more anastomotic dilatations.

With intensive preadmission pulmonary and physical conditioning, use

of a side-to-side staple technique (which has reduced the cervical

esophagogastric anastomotic leak rate to less than 3%), and

postoperative epidural anesthesia, the need for an intensive care unit

stay has been eliminated and the length of hospital stay was reduced

to 7 days. We concluded that THE can be achieved in most patients

requiring esophageal resection for benign and malignant disease and

with greater safety and less morbidity than the traditional

transthoracic approaches.

[Guest guest]

,

In response to your question as to what “anastomotic dilatation” is – it is a dilatation at the connection

area where they hook up your stomach to wherever your esophagus removal point

is. Dr. s in Rochester,

NY mentioned this to me as well

as a possibility. Basically it’s typically a result of too much scar

tissue forming. He indicated that the dilatation is very easy compared to what

we go through now with dilatations, and usually the people that need them tend

to need one or two and then that’s it. He did not give me a percentage of

how many he sees, but did not see it as a major side effect or risk.

Not to

trivialize any of this, but needing one or more anastomotic dilatations is the

least of our worries if we go through with this surgery.

in NY

From: achalasia [mailto:achalasia ] On Behalf Of cynmark24@...

Sent: Thursday, August 03, 2006 9:36 PM

achalasia

Subject: Re: Re:

Esophagus Removal Mortality

n,

Thank you for digging up the two abstracts on Esophagectomies, the

first being Achalasia specific. Along with the others who have posted

here about the mortality rates, those of us facing E'ectomies clearly

understand that since we are otherwise healthy our odds for success should

naturally be better than the overall average.

This is why it seems strange to me that when Dr. Altorki (the

thoracic surgeon) was " selling " me on the surgery, he quoted me a

number of 5% mortality for the operation knowing full well that I am not one of

his cancer patients. Why then, did he not say, that the mortality was 1%

for healthy achalasia patients. Doesn't make sense.

Maybe there is some kind of law or code of ethics here stating that when you

tell a patient the mortality stats you must tell them the hospital average, or

national average, and you're not permitted to give better statistics if

the patient does not fit the usual profile (cancer). Just a

thought. Maybe I'll ask my daughter that question.

He did give me a leak rate of 10% precisely matching the number you

quoted in the abstract (below).

n, it appears to me that this operation is no walk in the

park. It is full of places for things to go wrong, that get hidden

from view, such as

" Major

complications included anastomotic leak (10%), recurrent laryngeal nerve injury

(5%), delayed mediastinal bleeding requiring thoracotomy (2%), and chylothorax

(2%). There were 2 hospital deaths (2%) from respiratory insufficiency and

sepsis. "

And then to top it off

" nearly 50% have

required an anastomotic dilatation. "

Excuse me for a sec,

its time that I googled.

(15 minutes later)

I have to confess, I'm

having trouble nailing down exactly what it means. Here is a link for

anyone with more patience than I have at the moment.

Anastomotic

Complications after Esophagectomy - Karger Publishers

Whatever it is, its not

good and its at 50%.

If I must have the

surgery and there is no reliable alternative, then I am not feeling too good at

the moment as to what is in store for me.

I did not see a mention

either of acid reflux, considering what is going to be done with our poor

stomachs.

Clearly a lot of

thought must be given in order to make a decision that we can go forward

with.

Good, bad, or

otherwise, whoever brings to this Board additional information on

esophagectomies, I thank you. I thank you for providing me and

everyone else facing this with an additional information giving us a better

perspective. Many of the articles also contain extensive

bibliographies providing even more information.

In a message dated 8/3/2006 8:37:14 P.M. Eastern

Standard Time, rnbrielysbcglobal (DOT) net writes:

Here are two abstracts

on esophagectomies. The first is Achalasia specific, the second is more

general. Mortality rates were 2% (n=93patients) and 4% (n=1085 patients)

respecitvely. Perhaps another good number to focus on is the 95% of patients in

the first study who are eating well after the surgery.

Best wishes to all of you having to make this difficult decision.

Regards,

n

Abstract #1

Esophagectomy for achalasia: patient selection and clinical experience

Presented at the Thirty-seventh Annual Meeting of The Society of

Thoracic Surgeons, New Orleans,

LA, Jan 29–31, 2001.

J. Devaney MDa, Mark D. Iannettoni MDa, Mark B. Orringer

MDCorresponding Author Contact Information, E-mail The Corresponding

Author, a and Becky Marshalla

a Section of Thoracic Surgery, Department of Surgery, University of

Michigan Medical

Center, Ann Arbor, Michigan, USA

Abstract

Background. In 1989, we predicted an increasing number of

esophagectomies for megaesophagus and for recurrent symptoms after

prior esophagomyotomy or balloon dilatation for achalasia. Patient

selection in this group is challenging, as the potential operative

morbidity of an esophagectomy must be weighed against the expected

clinical outcome after a redo esophagomyotomy or alternative

procedures designed to salvage the native esophagus.

Methods. The hospital records of 93 patients undergoing esophagectomy

for achalasia during the past 20 years were reviewed retrospectively

and the results of operation assessed using our prospectively

established Esophageal Resection Database and follow-up information

obtained through personal contact with the patients.

Results. Patient age averaged 51 years. Indications for esophagectomy

included tortuous megaesophagus (64%), failure of prior myotomy (63%),

and associated reflux stricture (7%). Ninety-four percent of the

patients underwent a transhiatal esophagectomy. Stomach was used as

the esophageal substitute in 91% cases. Intraoperative blood loss

averaged 672 mL. Postoperative length of stay averaged 12.5 days.

Major complications included anastomotic leak (10%), recurrent

laryngeal nerve injury (5%), delayed mediastinal bleeding requiring

thoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths

(2%) from respiratory insufficiency and sepsis. Follow-up has averaged

38 months. In all, 95% of patients eat well; nearly 50% have required

an anastomotic dilatation; troublesome regurgitation has been rare;

and 4% have refractory postvagotomy dumping.

Conclusions. Esophagectomy, preferably through a transhiatal approach,

is generally safe and effective therapy in selected patients with

achalasia. Unique technical considerations include difficulty

encircling the dilated cervical esophagus, deviation of the esophagus

into the right chest, large aortic esophageal arteries, and adherence

of the exposed esophageal submucosa to the adjacent aorta after prior

myotomy.

Abstract #2

Transhiatal esophagectomy for treatment of benign and malignant

esophageal disease

Orringer, M B; Marshall, B; Iannettoni, M D

Section of General Thoracic Surgery, Department of Surgery, University

of Michigan Medical

Center, 2120 Taubman Health

Care Center,

1500 E.

Medical Center Drive,

Box 0344, Ann Arbor, Michigan 48109, USA;

e-mail

morrinumich (DOT) edu

Abstract

Since our initial 1978 report, we have performed transhiatal

esophagectomy (THE) in 1085 patients with intrathoracic esophageal

disease: 285 (26%) benign lesions and 800 (74%) malignant lesions

(4.5% upper, 22% middle, and 73.5% lower third/cardia). THE was

possible in 97% of patients in whom it was attempted; reconstruction

was performed at the same operation in all but six patients. The

esophageal substitute was positioned in the original esophageal bed in

98%, stomach being used in 782 patients (96%) and colon in those with

a prior gastric resection. Hospital mortality was 4%, with three

deaths due to uncontrollable intraoperative hemorrhage. Major

complications included anastomotic leak (13%), atelectasis/pneumonia

prolonging hospitalization (2%), recurrent laryngeal nerve paralysis,

chylothorax, and tracheal laceration (< 1% each). There were five

reoperations for mediastinal bleeding within 24 hours of THE.

Intraoperative blood loss averaged 689 ml. Altogether, 78% of the

patients had no postoperative complications. Actuarial survival of the

cancer patients mirrors that reported after transthoracic

esophagectomy. Late functional results are good or excellent in 80%.

Approximately 50% have required one or more anastomotic dilatations.

With intensive preadmission pulmonary and physical conditioning, use

of a side-to-side staple technique (which has reduced the cervical

esophagogastric anastomotic leak rate to less than 3%), and

postoperative epidural anesthesia, the need for an intensive care unit

stay has been eliminated and the length of hospital stay was reduced

to 7 days. We concluded that THE can be achieved in most patients

requiring esophageal resection for benign and malignant disease and

with greater safety and less morbidity than the traditional

transthoracic approaches.

[Guest guest]

I like www.onelook.com for definitions. Just enter a word once,

and it finds definitions in all kinds of dictionaries including

medical dictionaries.

I found this: " An anastomosis is a surgical connection between

two structures. It most commonly refers to a connection which is

created between tubular structures, such as blood vessels or

loops of intestine. For example, when a segment of intestine is

surgically removed, the two remaining ends are sewn or stapled

together (anastomosed), and the procedure is referred to as an

intestinal anastomosis. "

The article you mentioned includes this sentence: " The majority

of surgeons do prefer to use stomach to restore continuity

because of the relative simplicity of the operation and the need

for only one anastomosis. " In other words, there's only one new

connection (stomach to upper esophagus) rather than two (one at

each end of a piece of colon).

And this: " Dilatation of a leaking anastomosis may favorably

influence healing because relative narrowing by local

inflammation and spasm may contribute to obstruction ... and

adversely affect spontaneous closure. "

in PA

----- Original Message -----

From: <cynmark24@...>

<snip>

" nearly 50% have required an anastomotic dilatation. "

Excuse me for a sec, its time that I googled.

(15 minutes later)

I have to confess, I'm having trouble nailing down exactly what

it means.

Here is a link for anyone with more patience than I have at the

moment.

_Anastomotic Complications after Esophagectomy - Karger

Publishers_

(http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowFulltext & ProduktNr\

=223996 & Ausgabe=227627 & ArtikelNr=52018#SA2)

[Guest guest]

Why isn't Dr. s

in this forum?

M.

>

> ,

>

> In response to your question as to what " anastomotic dilatation "

is - it is

> a dilatation at the connection area where they hook up your

stomach to

> wherever your esophagus removal point is. Dr. s in Rochester,

NY

> mentioned this to me as well as a possibility. Basically it's

typically a

> result of too much scar tissue forming. He indicated that the

dilatation is

> very easy compared to what we go through now with dilatations, and

usually

> the people that need them tend to need one or two and then that's

it. He did

> not give me a percentage of how many he sees, but did not see it

as a major

> side effect or risk.

>

> Not to trivialize any of this, but needing one or more anastomotic

> dilatations is the least of our worries if we go through with this

surgery.

>

> in NY

>

>

>

> _____

>

> From: achalasia [mailto:achalasia ]

On Behalf

> Of cynmark24@...

> Sent: Thursday, August 03, 2006 9:36 PM

> achalasia

> Subject: Re: Re: Esophagus Removal Mortality

>

>

>

> n,

>

>

>

> Thank you for digging up the two abstracts on Esophagectomies,

the first

> being Achalasia specific. Along with the others who have posted

here about

> the mortality rates, those of us facing E'ectomies clearly

understand that

> since we are otherwise healthy our odds for success should

naturally be

> better than the overall average.

>

>

>

> This is why it seems strange to me that when Dr. Altorki (the

thoracic

> surgeon) was " selling " me on the surgery, he quoted me a number of

5%

> mortality for the operation knowing full well that I am not one of

his

> cancer patients. Why then, did he not say, that the mortality was

1% for

> healthy achalasia patients. Doesn't make sense. Maybe there is

some kind

> of law or code of ethics here stating that when you tell a patient

the

> mortality stats you must tell them the hospital average, or

national

> average, and you're not permitted to give better statistics if the

patient

> does not fit the usual profile (cancer). Just a thought. Maybe

I'll ask my

> daughter that question.

>

>

>

> He did give me a leak rate of 10% precisely matching the

number you

> quoted in the abstract (below).

>

>

>

> n, it appears to me that this operation is no walk in

the park.

> It is full of places for things to go wrong, that get hidden from

view, such

> as

>

>

>

> " Major complications included anastomotic leak (10%), recurrent

laryngeal

> nerve injury (5%), delayed mediastinal bleeding requiring

thoracotomy (2%),

> and chylothorax (2%). There were 2 hospital deaths (2%) from

respiratory

> insufficiency and sepsis. "

>

>

>

> And then to top it off

>

>

>

> " nearly 50% have required an anastomotic dilatation. "

>

>

>

> Excuse me for a sec, its time that I googled.

>

>

>

> (15 minutes later)

>

> I have to confess, I'm having trouble nailing down exactly what it

means.

> Here is a link for anyone with more patience than I have at the

moment.

>

>

>

>

>

> Anastomotic

> <http://content.karger.com/ProdukteDB/produkte.asp?

Aktion=ShowFulltext & Produ

> ktNr=223996 & Ausgabe=227627 & ArtikelNr=52018#SA2> Complications

after

> Esophagectomy - Karger Publishers

>

>

>

> Whatever it is, its not good and its at 50%.

>

>

>

> If I must have the surgery and there is no reliable alternative,

then I am

> not feeling too good at the moment as to what is in store for me.

>

>

>

> I did not see a mention either of acid reflux, considering what is

going to

> be done with our poor stomachs.

>

>

>

> Clearly a lot of thought must be given in order to make a decision

that we

> can go forward with.

>

>

>

> Good, bad, or otherwise, whoever brings to this Board additional

information

> on esophagectomies, I thank you. I thank you for providing me

and everyone

> else facing this with an additional information giving us a better

> perspective. Many of the articles also contain extensive

bibliographies

> providing even more information.

>

>

>

>

>

>

>

>

>

> In a message dated 8/3/2006 8:37:14 P.M. Eastern Standard Time,

> rnbriely@... writes:

>

> Here are two abstracts on esophagectomies. The first is Achalasia

specific,

> the second is more general. Mortality rates were 2% (n=93patients)

and 4%

> (n=1085 patients) respecitvely. Perhaps another good number to

focus on is

> the 95% of patients in the first study who are eating well after

the

> surgery.

>

> Best wishes to all of you having to make this difficult decision.

>

> Regards,

> n

>

> Abstract #1

> Esophagectomy for achalasia: patient selection and clinical

experience

>

> Presented at the Thirty-seventh Annual Meeting of The Society of

> Thoracic Surgeons, New Orleans, LA, Jan 29-31, 2001.

>

> J. Devaney MDa, Mark D. Iannettoni MDa, Mark B. Orringer

> MDCorresponding Author Contact Information, E-mail The

Corresponding

> Author, a and Becky Marshalla

>

> a Section of Thoracic Surgery, Department of Surgery, University of

> Michigan Medical Center, Ann Arbor, Michigan, USA

>

> Abstract

>

> Background. In 1989, we predicted an increasing number of

> esophagectomies for megaesophagus and for recurrent symptoms after

> prior esophagomyotomy or balloon dilatation for achalasia. Patient

> selection in this group is challenging, as the potential operative

> morbidity of an esophagectomy must be weighed against the expected

> clinical outcome after a redo esophagomyotomy or alternative

> procedures designed to salvage the native esophagus.

>

> Methods. The hospital records of 93 patients undergoing

esophagectomy

> for achalasia during the past 20 years were reviewed

retrospectively

> and the results of operation assessed using our prospectively

> established Esophageal Resection Database and follow-up information

> obtained through personal contact with the patients.

>

> Results. Patient age averaged 51 years. Indications for

esophagectomy

> included tortuous megaesophagus (64%), failure of prior myotomy

(63%),

> and associated reflux stricture (7%). Ninety-four percent of the

> patients underwent a transhiatal esophagectomy. Stomach was used as

> the esophageal substitute in 91% cases. Intraoperative blood loss

> averaged 672 mL. Postoperative length of stay averaged 12.5 days.

> Major complications included anastomotic leak (10%), recurrent

> laryngeal nerve injury (5%), delayed mediastinal bleeding requiring

> thoracotomy (2%), and chylothorax (2%). There were 2 hospital

deaths

> (2%) from respiratory insufficiency and sepsis. Follow-up has

averaged

> 38 months. In all, 95% of patients eat well; nearly 50% have

required

> an anastomotic dilatation; troublesome regurgitation has been rare;

> and 4% have refractory postvagotomy dumping.

>

> Conclusions. Esophagectomy, preferably through a transhiatal

approach,

> is generally safe and effective therapy in selected patients with

> achalasia. Unique technical considerations include difficulty

> encircling the dilated cervical esophagus, deviation of the

esophagus

> into the right chest, large aortic esophageal arteries, and

adherence

> of the exposed esophageal submucosa to the adjacent aorta after

prior

> myotomy.

>

> Abstract #2

> Transhiatal esophagectomy for treatment of benign and malignant

> esophageal disease

>

> Orringer, M B; Marshall, B; Iannettoni, M D

>

> Section of General Thoracic Surgery, Department of Surgery,

University

> of Michigan Medical Center, 2120 Taubman Health Care Center, 1500

E.

> Medical Center Drive, Box 0344, Ann Arbor, Michigan 48109, USA; e-

mail

> morrinumich (DOT) <mailto:morrin%40umich.edu> edu

>

> Abstract

>

> Since our initial 1978 report, we have performed transhiatal

> esophagectomy (THE) in 1085 patients with intrathoracic esophageal

> disease: 285 (26%) benign lesions and 800 (74%) malignant lesions

> (4.5% upper, 22% middle, and 73.5% lower third/cardia). THE was

> possible in 97% of patients in whom it was attempted;

reconstruction

> was performed at the same operation in all but six patients. The

> esophageal substitute was positioned in the original esophageal

bed in

> 98%, stomach being used in 782 patients (96%) and colon in those

with

> a prior gastric resection. Hospital mortality was 4%, with three

> deaths due to uncontrollable intraoperative hemorrhage. Major

> complications included anastomotic leak (13%),

atelectasis/pneumonia

> prolonging hospitalization (2%), recurrent laryngeal nerve

paralysis,

> chylothorax, and tracheal laceration (< 1% each). There were five

> reoperations for mediastinal bleeding within 24 hours of THE.

> Intraoperative blood loss averaged 689 ml. Altogether, 78% of the

> patients had no postoperative complications. Actuarial survival of

the

> cancer patients mirrors that reported after transthoracic

> esophagectomy. Late functional results are good or excellent in

80%.

> Approximately 50% have required one or more anastomotic

dilatations.

> With intensive preadmission pulmonary and physical conditioning,

use

> of a side-to-side staple technique (which has reduced the cervical

> esophagogastric anastomotic leak rate to less than 3%), and

> postoperative epidural anesthesia, the need for an intensive care

unit

> stay has been eliminated and the length of hospital stay was

reduced

> to 7 days. We concluded that THE can be achieved in most patients

> requiring esophageal resection for benign and malignant disease and

> with greater safety and less morbidity than the traditional

> transthoracic approaches.

>

[Guest guest]

Woah !

Anastomotic...there's a spelling bee

word for ya.

>

>

> Hi ,

>

> Your response, as well as in Pa., is helping to bring

me more " up

> to speed, " and will enable me to ask far more probing questions

when I speak

> with the next surgeon. Thanks.

>

>

>

> In a message dated 8/3/2006 11:03:54 P.M. Eastern Standard Time,

> tracylb@... writes:

>

>

>

>

>

> ,

> In response to your question as to what “anastomotic

dilatation†is †" it

> is a dilatation at the connection area where they hook up your

stomach to

> wherever your esophagus removal point is. Dr. s in is ,

mentioned this

> to me as well as a possibility. Basically it’s typically a

result of too much

> scar tissue forming. He indicated that the dilatation is very

easy compared

> to what we go through now with dilatations, and usually the

people that need

> them tend to need one or two and then that’s it. He did not

give me a

> percentage of how many he sees, but did not see it as a major

side effect or risk.

> Not to trivialize any of this, but needing one or more

anastomotic

> dilatations is the least of our worries if we go through with

this surgery.

> in NY

>

>

> ____________________________________

>

> From: <ST1>achalasia [mailto: [mailto:<ST1>a [] On Behalf

Of

> cynmark24@...

> Sent: Thursday, Thursday, <ST1>Aug <ST1>9

> <ST1>achalasia

> Subject: Re: Re: Esophagus Removal Mortality

>

>

>

>

>

> n,

>

>

>

> Thank you for digging up the two abstracts on Esophagectomies,

the first

> being Achalasia specific. Along with the others who have posted

here about the

> mortality rates, those of us facing E'ectomies clearly understand

that since

> we are otherwise healthy our odds for success should naturally be

better than

> the overall average.

>

>

>

> This is why it seems strange to me that when Dr. Altorki (the

thoracic

> surgeon) was " selling " me on the surgery, he quoted me a number

of 5% mortality

> for the operation knowing full well that I am not one of his

cancer patients.

> Why then, did he not say, that the mortality was 1% for healthy

achalasia

> patients. Doesn't make sense. Maybe there is some kind of law

or code of

> ethics here stating that when you tell a patient the mortality

stats you must

> tell them the hospital average, or national average, and you're

not permitted

> to give better statistics if the patient does not fit the usual

profile

> (cancer). Just a thought. Maybe I'll ask my daughter that

question.

>

>

>

> He did give me a leak rate of 10% precisely matching the number

you quoted

> in the abstract (below).

>

>

>

> n, it appears to me that this operation is no walk in the

park. It is

> full of places for things to go wrong, that get hidden from view,

such as

>

>

>

> " Major complications included anastomotic leak (10%), recurrent

laryngeal

> nerve injury (5%), delayed mediastinal bleeding requiring

thoracotomy (2%), and

> chylothorax (2%). There were 2 hospital deaths (2%) from

respiratory

> insufficiency and sepsis. "

>

>

>

> And then to top it off

>

>

>

> " nearly 50% have required an anastomotic dilatation. "

>

>

>

> Excuse me for a sec, its time that I googled.

>

>

>

> (15 minutes later)

>

> I have to confess, I'm having trouble nailing down exactly what

it means.

> Here is a link for anyone with more patience than I have at the

moment.

>

>

>

>

>

> _Anastomotic Complications after Esophagectomy - Karger

Publishers_

> (http://content.karger.com/ProdukteDB/produkte.asp?

Aktion=ShowFulltext & ProduktNr=223996

> & Ausgabe=227627 & ArtikelNr=52018#SA2)

>

>

>

> Whatever it is, its not good and its at 50%.

>

>

>

> If I must have the surgery and there is no reliable alternative,

then I am

> not feeling too good at the moment as to what is in store for

me.

>

>

>

> I did not see a mention either of acid reflux, considering what

is going to

> be done with our poor stomachs.

>

>

>

> Clearly a lot of thought must be given in order to make a

decision that we

> can go forward with.

>

>

>

> Good, bad, or otherwise, whoever brings to this Board additional

information

> on esophagectomies, I thank you. I thank you for providing me

and

> everyone else facing this with an additional information giving us

a better

> perspective. Many of the articles also contain extensive

bibliographies providing

> even more information.

>

>

>

>

>

>

>

>

>

> In a message dated In a mes 8:37:14 P.M. Eastern Standard Time,

> rnbrielysbcglobal (DOT) 8:37:14 P.

>

>

>

>

> Here are two abstracts on esophagectomies. The first is Achalasia

specific,

> the second is more general. Mortality rates were 2%

(n=93patients) and 4%

> (n=1085 patients) respecitvely. Perhaps another good number to

focus on is the

> 95% of patients in the first study who are eating well after the

surgery.

>

> Best wishes to all of you having to make this difficult decision.

>

> Regards,

> n

>

> Abstract #1

> Esophagectomy for achalasia: patient selection and clinical

experience

>

> Presented at the Thirty-seventh Annual Meeting of The Society of

> Thoracic Surgeons, Thoracic Su, , , Jan 29†" 31, 2001.

>

> J. Devaney MDa, Mark D. Iannettoni MDa, Mark B. Orringer

> MDCorresponding Author Contact Information, E-mail The

Corresponding

> Author, a and Becky Marshalla

>

> a Section of Thoracic Surgery, Department of Surgery, University

of

> <ST1>Mic <ST1>, , <ST1><S, , , ,

>

> Abstract

>

> Background. In 1989, we predicted an increasing number of

> esophagectomies for megaesophagus and for recurrent symptoms after

> prior esophagomyotomy or balloon dilatation for achalasia. Patient

> selection in this group is challenging, as the potential operative

> morbidity of an esophagectomy must be weighed against the expected

> clinical outcome after a redo esophagomyotomy or alternative

> procedures designed to salvage the native esophagus.

>

> Methods. The hospital records of 93 patients undergoing

esophagectomy

> for achalasia during the past 20 years were reviewed

retrospectively

> and the results of operation assessed using our prospectively

> established Esophageal Resection Database and follow-up

information

> obtained through personal contact with the patients.

>

> Results. Patient age averaged 51 years. Indications for

esophagectomy

> included tortuous megaesophagus (64%), failure of prior myotomy

(63%),

> and associated reflux stricture (7%). Ninety-four percent of the

> patients underwent a transhiatal esophagectomy. Stomach was used

as

> the esophageal substitute in 91% cases. Intraoperative blood loss

> averaged 672 mL. Postoperative length of stay averaged 12.5 days.

> Major complications included anastomotic leak (10%), recurrent

> laryngeal nerve injury (5%), delayed mediastinal bleeding

requiring

> thoracotomy (2%), and chylothorax (2%). There were 2 hospital

deaths

> (2%) from respiratory insufficiency and sepsis. Follow-up has

averaged

> 38 months. In all, 95% of patients eat well; nearly 50% have

required

> an anastomotic dilatation; troublesome regurgitation has been

rare;

> and 4% have refractory postvagotomy dumping.

>

> Conclusions. Esophagectomy, preferably through a transhiatal

approach,

> is generally safe and effective therapy in selected patients with

> achalasia. Unique technical considerations include difficulty

> encircling the dilated cervical esophagus, deviation of the

esophagus

> into the right chest, large aortic esophageal arteries, and

adherence

> of the exposed esophageal submucosa to the adjacent aorta after

prior

> myotomy.

>

> Abstract #2

> Transhiatal esophagectomy for treatment of benign and malignant

> esophageal disease

>

> Orringer, M B; Marshall, B; Iannettoni, M D

>

> Section of General Thoracic Surgery, Department of Surgery,

University

> of of <ST1> <ST1>M , 2120 , 2120 <ST1> <ST1>, 1500 E.

> <ST1><ST1>Medical Center , , <ST1>, , <ST1>An, , <ST1, , ; e-mail

> _morrin@..._ (mailto:morrin@...)

>

> Abstract

>

> Since our initial 1978 report, we have performed transhiatal

> esophagectomy (THE) in 1085 patients with intrathoracic esophageal

> disease: 285 (26%) benign lesions and 800 (74%) malignant lesions

> (4.5% upper, 22% middle, and 73.5% lower third/cardia)(4.5% upp

> possible in 97% of patients in whom it was attempted;

reconstruction

> was performed at the same operation in all but six patients. The

> esophageal substitute was positioned in the original esophageal

bed in

> 98%, stomach being used in 782 patients (96%) and colon in those

with

> a prior gastric resection. Hospital mortality was 4%, with three

> deaths due to uncontrollable intraoperative hemorrhage. Major

> complications included anastomotic leak (13%),

atelectasis/complicat

> prolonging hospitalization (2%), recurrent laryngeal nerve

paralysis,

> chylothorax, and tracheal laceration (< 1% each). There were five

> reoperations for mediastinal bleeding within 24 hours of THE.

> Intraoperative blood loss averaged 689 ml. Altogether, 78% of the

> patients had no postoperative complications. Actuarial survival

of the

> cancer patients mirrors that reported after transthoracic

> esophagectomy. Late functional results are good or excellent in

80%.

> Approximately 50% have required one or more anastomotic

dilatations.

> With intensive preadmission pulmonary and physical conditioning,

use

> of a side-to-side staple technique (which has reduced the cervical

> esophagogastric anastomotic leak rate to less than 3%), and

> postoperative epidural anesthesia, the need for an intensive care

unit

> stay has been eliminated and the length of hospital stay was

reduced

> to 7 days. We concluded that THE can be achieved in most patients

> requiring esophageal resection for benign and malignant disease

and

> with greater safety and less morbidity than the traditional

> transthoracic approaches.

>

[Guest guest]

Gawd, but the posts lately are as scary as hell. The surgeries and severity of same scare me. I send my sympathies to and I hope that things work out all right for him. I, myself, am having NCCP's like mad, trouble sleeping, trouble eating or drinking and sticking feelings again. No foam yet, but the coughing is back. Food does not look good. I have trouble getting water down sometimes. The moderate chest pains make me bummed out from time to time but still, I am better than before my VAT in late Jan. of this year. I am having sharp throat pain but I think maybe it's only acid reflux. So. What else is new? Not much. But I am getting ready to sell my place at the beach. My expenses for out-of-pocket/ out-of-service visits,

expensive meds ($1000. a month), psych. visits and other things, plus not having my usual income ( being depressed and then sick and then post-op and self-employed means no paid sick leave and no income while I was ill), has used up quite a bit of my savings. So, I'll be looking for a less expensive place to live. Maybe I should be a deckmate on The Black Pearl with Capt. Jack Sparrow! Love that guy! AND his undereye shadows! wishing everyone out there good health, Deborah

[Guest guest]

Dear ,

I haven't mentioned what a joy it was to meet you. It is so much more fun to read messages when you even slightly know the person behind them.

About Dr. s.... He was just moving when I was looking at surgery... he was definitely the go-to guy at the time, but was moving to the East Coast. Since then his name doesn't often pop up. Maybe he went different directions in his practice. He must be on a website somewhere, maybe there is a hint there? Is he getting older and starting to retire maybe? His published a lot of articles in the past but doesn't seem like he does as much now.

I'm sure he'd love to talk to you though.

Sandy in So Cal....hmmmmmmm

> >> > ,> > > > In response to your question as to what "anastomotic dilatation" > is - it is> > a dilatation at the connection area where they hook up your > stomach to> > wherever your esophagus removal point is. Dr. s in Rochester, > NY> > mentioned this to me as well as a possibility. Basically it's > typically a> > result of too much scar tissue forming. He indicated that the > dilatation is> > very easy compared to what we go through now with dilatations, and > usually> > the people that need them tend to need one or two and then that's > it. He did> > not give me a percentage of how many he sees, but did not see it > as a major> > side effect or risk. > > > > Not to trivialize any of this, but needing one or more anastomotic> > dilatations is the least of our worries if we go through with this > surgery. > > > > in NY> > > > > > > > _____ > > > > From: achalasia [mailto:achalasia ] > On Behalf> > Of cynmark24@> > Sent: Thursday, August 03, 2006 9:36 PM> > achalasia > > Subject: Re: Re: Esophagus Removal Mortality> > > > > > > > n,> > > > > > > > Thank you for digging up the two abstracts on Esophagectomies, > the first> > being Achalasia specific. Along with the others who have posted > here about> > the mortality rates, those of us facing E'ectomies clearly > understand that> > since we are otherwise healthy our odds for success should > naturally be> > better than the overall average.> > > > > > > > This is why it seems strange to me that when Dr. Altorki (the > thoracic> > surgeon) was "selling" me on the surgery, he quoted me a number of > 5%> > mortality for the operation knowing full well that I am not one of > his> > cancer patients. Why then, did he not say, that the mortality was > 1% for> > healthy achalasia patients. Doesn't make sense. Maybe there is > some kind> > of law or code of ethics here stating that when you tell a patient > the> > mortality stats you must tell them the hospital average, or > national> > average, and you're not permitted to give better statistics if the > patient> > does not fit the usual profile (cancer). Just a thought. Maybe > I'll ask my> > daughter that question.> > > > > > > > He did give me a leak rate of 10% precisely matching the > number you> > quoted in the abstract (below).> > > > > > > > n, it appears to me that this operation is no walk in > the park.> > It is full of places for things to go wrong, that get hidden from > view, such> > as > > > > > > > > "Major complications included anastomotic leak (10%), recurrent > laryngeal> > nerve injury (5%), delayed mediastinal bleeding requiring > thoracotomy (2%),> > and chylothorax (2%). There were 2 hospital deaths (2%) from > respiratory> > insufficiency and sepsis."> > > > > > > > And then to top it off> > > > > > > > "nearly 50% have required an anastomotic dilatation."> > > > > > > > Excuse me for a sec, its time that I googled.> > > > > > > > (15 minutes later)> > > > I have to confess, I'm having trouble nailing down exactly what it > means.> > Here is a link for anyone with more patience than I have at the > moment.> > > > > > > > > > > > Anastomotic> > <http://content.karger.com/ProdukteDB/produkte.asp?> Aktion=ShowFulltext & Produ> > ktNr=223996 & Ausgabe=227627 & ArtikelNr=52018#SA2> Complications > after> > Esophagectomy - Karger Publishers > > > > > > > > Whatever it is, its not good and its at 50%.> > > > > > > > If I must have the surgery and there is no reliable alternative, > then I am> > not feeling too good at the moment as to what is in store for me. > > > > > > > > I did not see a mention either of acid reflux, considering what is > going to> > be done with our poor stomachs.> > > > > > > > Clearly a lot of thought must be given in order to make a decision > that we> > can go forward with. > > > > > > > > Good, bad, or otherwise, whoever brings to this Board additional > information> > on esophagectomies, I thank you. I thank you for providing me > and everyone> > else facing this with an additional information giving us a better> > perspective. Many of the articles also contain extensive > bibliographies> > providing even more information. > > > > > > > > > > > > > > > > > > > > In a message dated 8/3/2006 8:37:14 P.M. Eastern Standard Time,> > rnbriely@ writes:> > > > Here are two abstracts on esophagectomies. The first is Achalasia > specific,> > the second is more general. Mortality rates were 2% (n=93patients) > and 4%> > (n=1085 patients) respecitvely. Perhaps another good number to > focus on is> > the 95% of patients in the first study who are eating well after > the> > surgery. > > > > Best wishes to all of you having to make this difficult decision. > > > > Regards, > > n > > > > Abstract #1> > Esophagectomy for achalasia: patient selection and clinical > experience> > > > Presented at the Thirty-seventh Annual Meeting of The Society of> > Thoracic Surgeons, New Orleans, LA, Jan 29-31, 2001.> > > > J. Devaney MDa, Mark D. Iannettoni MDa, Mark B. Orringer> > MDCorresponding Author Contact Information, E-mail The > Corresponding> > Author, a and Becky Marshalla> > > > a Section of Thoracic Surgery, Department of Surgery, University of> > Michigan Medical Center, Ann Arbor, Michigan, USA> > > > Abstract> > > > Background. In 1989, we predicted an increasing number of> > esophagectomies for megaesophagus and for recurrent symptoms after> > prior esophagomyotomy or balloon dilatation for achalasia. Patient> > selection in this group is challenging, as the potential operative> > morbidity of an esophagectomy must be weighed against the expected> > clinical outcome after a redo esophagomyotomy or alternative> > procedures designed to salvage the native esophagus.> > > > Methods. The hospital records of 93 patients undergoing > esophagectomy> > for achalasia during the past 20 years were reviewed > retrospectively> > and the results of operation assessed using our prospectively> > established Esophageal Resection Database and follow-up information> > obtained through personal contact with the patients.> > > > Results. Patient age averaged 51 years. Indications for > esophagectomy> > included tortuous megaesophagus (64%), failure of prior myotomy > (63%),> > and associated reflux stricture (7%). Ninety-four percent of the> > patients underwent a transhiatal esophagectomy. Stomach was used as> > the esophageal substitute in 91% cases. Intraoperative blood loss> > averaged 672 mL. Postoperative length of stay averaged 12.5 days.> > Major complications included anastomotic leak (10%), recurrent> > laryngeal nerve injury (5%), delayed mediastinal bleeding requiring> > thoracotomy (2%), and chylothorax (2%). There were 2 hospital > deaths> > (2%) from respiratory insufficiency and sepsis. Follow-up has > averaged> > 38 months. In all, 95% of patients eat well; nearly 50% have > required> > an anastomotic dilatation; troublesome regurgitation has been rare;> > and 4% have refractory postvagotomy dumping.> > > > Conclusions. Esophagectomy, preferably through a transhiatal > approach,> > is generally safe and effective therapy in selected patients with> > achalasia. Unique technical considerations include difficulty> > encircling the dilated cervical esophagus, deviation of the > esophagus> > into the right chest, large aortic esophageal arteries, and > adherence> > of the exposed esophageal submucosa to the adjacent aorta after > prior> > myotomy. > > > > Abstract #2> > Transhiatal esophagectomy for treatment of benign and malignant> > esophageal disease> > > > Orringer, M B; Marshall, B; Iannettoni, M D> > > > Section of General Thoracic Surgery, Department of Surgery, > University> > of Michigan Medical Center, 2120 Taubman Health Care Center, 1500 > E.> > Medical Center Drive, Box 0344, Ann Arbor, Michigan 48109, USA; e-> mail> > morrinumich (DOT) <mailto:morrin%40umich.edu> edu> > > > Abstract> > > > Since our initial 1978 report, we have performed transhiatal> > esophagectomy (THE) in 1085 patients with intrathoracic esophageal> > disease: 285 (26%) benign lesions and 800 (74%) malignant lesions> > (4.5% upper, 22% middle, and 73.5% lower third/cardia). THE was> > possible in 97% of patients in whom it was attempted; > reconstruction> > was performed at the same operation in all but six patients. The> > esophageal substitute was positioned in the original esophageal > bed in> > 98%, stomach being used in 782 patients (96%) and colon in those > with> > a prior gastric resection. Hospital mortality was 4%, with three> > deaths due to uncontrollable intraoperative hemorrhage. Major> > complications included anastomotic leak (13%), > atelectasis/pneumonia> > prolonging hospitalization (2%), recurrent laryngeal nerve > paralysis,> > chylothorax, and tracheal laceration (< 1% each). There were five> > reoperations for mediastinal bleeding within 24 hours of THE.> > Intraoperative blood loss averaged 689 ml. Altogether, 78% of the> > patients had no postoperative complications. Actuarial survival of > the> > cancer patients mirrors that reported after transthoracic> > esophagectomy. Late functional results are good or excellent in > 80%.> > Approximately 50% have required one or more anastomotic > dilatations.> > With intensive preadmission pulmonary and physical conditioning, > use> > of a side-to-side staple technique (which has reduced the cervical> > esophagogastric anastomotic leak rate to less than 3%), and> > postoperative epidural anesthesia, the need for an intensive care > unit> > stay has been eliminated and the length of hospital stay was > reduced> > to 7 days. We concluded that THE can be achieved in most patients> > requiring esophageal resection for benign and malignant disease and> > with greater safety and less morbidity than the traditional> > transthoracic approaches.> >>

[Guest guest]

definitely a blessed event!

> > >

> > > ,

> > >

> > > In response to your question as to what " anastomotic

dilatation "

> > is - it is

> > > a dilatation at the connection area where they hook up your

> > stomach to

> > > wherever your esophagus removal point is. Dr. s in

Rochester,

> > NY

> > > mentioned this to me as well as a possibility. Basically it's

> > typically a

> > > result of too much scar tissue forming. He indicated that the

> > dilatation is

> > > very easy compared to what we go through now with dilatations,

and

> > usually

> > > the people that need them tend to need one or two and then

that's

> > it. He did

> > > not give me a percentage of how many he sees, but did not see

it

> > as a major

> > > side effect or risk.

> > >

> > > Not to trivialize any of this, but needing one or more

anastomotic

> > > dilatations is the least of our worries if we go through with

this

> > surgery.

> > >

> > > in NY

> > >

> > >

> > >

> > > _____

> > >

> > > From: achalasia

[mailto:achalasia ]

> > On Behalf

> > > Of cynmark24@

> > > Sent: Thursday, August 03, 2006 9:36 PM

> > > achalasia

> > > Subject: Re: Re: Esophagus Removal Mortality

> > >

> > >

> > >

> > > n,

> > >

> > >

> > >

> > > Thank you for digging up the two abstracts on Esophagectomies,

> > the first

> > > being Achalasia specific. Along with the others who have posted

> > here about

> > > the mortality rates, those of us facing E'ectomies clearly

> > understand that

> > > since we are otherwise healthy our odds for success should

> > naturally be

> > > better than the overall average.

> > >

> > >

> > >

> > > This is why it seems strange to me that when Dr. Altorki (the

> > thoracic

> > > surgeon) was " selling " me on the surgery, he quoted me a

number of

> > 5%

> > > mortality for the operation knowing full well that I am not

one of

> > his

> > > cancer patients. Why then, did he not say, that the mortality

was

> > 1% for

> > > healthy achalasia patients. Doesn't make sense. Maybe there is

> > some kind

> > > of law or code of ethics here stating that when you tell a

patient

> > the

> > > mortality stats you must tell them the hospital average, or

> > national

> > > average, and you're not permitted to give better statistics if

the

> > patient

> > > does not fit the usual profile (cancer). Just a thought. Maybe

> > I'll ask my

> > > daughter that question.

> > >

> > >

> > >

> > > He did give me a leak rate of 10% precisely matching the

> > number you

> > > quoted in the abstract (below).

> > >

> > >

> > >

> > > n, it appears to me that this operation is no walk in

> > the park.

> > > It is full of places for things to go wrong, that get hidden

from

> > view, such

> > > as

> > >

> > >

> > >

> > > " Major complications included anastomotic leak (10%), recurrent

> > laryngeal

> > > nerve injury (5%), delayed mediastinal bleeding requiring

> > thoracotomy (2%),

> > > and chylothorax (2%). There were 2 hospital deaths (2%) from

> > respiratory

> > > insufficiency and sepsis. "

> > >

> > >

> > >

> > > And then to top it off

> > >

> > >

> > >

> > > " nearly 50% have required an anastomotic dilatation. "

> > >

> > >

> > >

> > > Excuse me for a sec, its time that I googled.

> > >

> > >

> > >

> > > (15 minutes later)

> > >

> > > I have to confess, I'm having trouble nailing down exactly

what it

> > means.

> > > Here is a link for anyone with more patience than I have at the

> > moment.

> > >

> > >

> > >

> > >

> > >

> > > Anastomotic

> > > <http://content.karger.com/ProdukteDB/produkte.asp?

> > Aktion=ShowFulltext & Produ

> > > ktNr=223996 & Ausgabe=227627 & ArtikelNr=52018#SA2> Complications

> > after

> > > Esophagectomy - Karger Publishers

> > >

> > >

> > >

> > > Whatever it is, its not good and its at 50%.

> > >

> > >

> > >

> > > If I must have the surgery and there is no reliable

alternative,

> > then I am

> > > not feeling too good at the moment as to what is in store for

me.

> > >

> > >

> > >

> > > I did not see a mention either of acid reflux, considering

what is

> > going to

> > > be done with our poor stomachs.

> > >

> > >

> > >

> > > Clearly a lot of thought must be given in order to make a

decision

> > that we

> > > can go forward with.

> > >

> > >

> > >

> > > Good, bad, or otherwise, whoever brings to this Board

additional

> > information

> > > on esophagectomies, I thank you. I thank you for providing me

> > and everyone

> > > else facing this with an additional information giving us a

better

> > > perspective. Many of the articles also contain extensive

> > bibliographies

> > > providing even more information.

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > > In a message dated 8/3/2006 8:37:14 P.M. Eastern Standard Time,

> > > rnbriely@ writes:

> > >

> > > Here are two abstracts on esophagectomies. The first is

Achalasia

> > specific,

> > > the second is more general. Mortality rates were 2%

(n=93patients)

> > and 4%

> > > (n=1085 patients) respecitvely. Perhaps another good number to

> > focus on is

> > > the 95% of patients in the first study who are eating well

after

> > the

> > > surgery.

> > >

> > > Best wishes to all of you having to make this difficult

decision.

> > >

> > > Regards,

> > > n

> > >

> > > Abstract #1

> > > Esophagectomy for achalasia: patient selection and clinical

> > experience

> > >

> > > Presented at the Thirty-seventh Annual Meeting of The Society

of

> > > Thoracic Surgeons, New Orleans, LA, Jan 29-31, 2001.

> > >

> > > J. Devaney MDa, Mark D. Iannettoni MDa, Mark B. Orringer

> > > MDCorresponding Author Contact Information, E-mail The

> > Corresponding

> > > Author, a and Becky Marshalla

> > >

> > > a Section of Thoracic Surgery, Department of Surgery,

University of

> > > Michigan Medical Center, Ann Arbor, Michigan, USA

> > >

> > > Abstract

> > >

> > > Background. In 1989, we predicted an increasing number of

> > > esophagectomies for megaesophagus and for recurrent symptoms

after

> > > prior esophagomyotomy or balloon dilatation for achalasia.

Patient

> > > selection in this group is challenging, as the potential

operative

> > > morbidity of an esophagectomy must be weighed against the

expected

> > > clinical outcome after a redo esophagomyotomy or alternative

> > > procedures designed to salvage the native esophagus.

> > >

> > > Methods. The hospital records of 93 patients undergoing

> > esophagectomy

> > > for achalasia during the past 20 years were reviewed

> > retrospectively

> > > and the results of operation assessed using our prospectively

> > > established Esophageal Resection Database and follow-up

information

> > > obtained through personal contact with the patients.

> > >

> > > Results. Patient age averaged 51 years. Indications for

> > esophagectomy

> > > included tortuous megaesophagus (64%), failure of prior myotomy

> > (63%),

> > > and associated reflux stricture (7%). Ninety-four percent of

the

> > > patients underwent a transhiatal esophagectomy. Stomach was

used as

> > > the esophageal substitute in 91% cases. Intraoperative blood

loss

> > > averaged 672 mL. Postoperative length of stay averaged 12.5

days.

> > > Major complications included anastomotic leak (10%), recurrent

> > > laryngeal nerve injury (5%), delayed mediastinal bleeding

requiring

> > > thoracotomy (2%), and chylothorax (2%). There were 2 hospital

> > deaths

> > > (2%) from respiratory insufficiency and sepsis. Follow-up has

> > averaged

> > > 38 months. In all, 95% of patients eat well; nearly 50% have

> > required

> > > an anastomotic dilatation; troublesome regurgitation has been

rare;

> > > and 4% have refractory postvagotomy dumping.

> > >

> > > Conclusions. Esophagectomy, preferably through a transhiatal

> > approach,

> > > is generally safe and effective therapy in selected patients

with

> > > achalasia. Unique technical considerations include difficulty

> > > encircling the dilated cervical esophagus, deviation of the

> > esophagus

> > > into the right chest, large aortic esophageal arteries, and

> > adherence

> > > of the exposed esophageal submucosa to the adjacent aorta after

> > prior

> > > myotomy.

> > >

> > > Abstract #2

> > > Transhiatal esophagectomy for treatment of benign and malignant

> > > esophageal disease

> > >

> > > Orringer, M B; Marshall, B; Iannettoni, M D

> > >

> > > Section of General Thoracic Surgery, Department of Surgery,

> > University

> > > of Michigan Medical Center, 2120 Taubman Health Care Center,

1500

> > E.

> > > Medical Center Drive, Box 0344, Ann Arbor, Michigan 48109,

USA; e-

> > mail

> > > morrinumich (DOT) <mailto:morrin%40umich.edu> edu

> > >

> > > Abstract

> > >

> > > Since our initial 1978 report, we have performed transhiatal

> > > esophagectomy (THE) in 1085 patients with intrathoracic

esophageal

> > > disease: 285 (26%) benign lesions and 800 (74%) malignant

lesions

> > > (4.5% upper, 22% middle, and 73.5% lower third/cardia). THE was

> > > possible in 97% of patients in whom it was attempted;

> > reconstruction

> > > was performed at the same operation in all but six patients.

The

> > > esophageal substitute was positioned in the original esophageal

> > bed in

> > > 98%, stomach being used in 782 patients (96%) and colon in

those

> > with

> > > a prior gastric resection. Hospital mortality was 4%, with

three

> > > deaths due to uncontrollable intraoperative hemorrhage. Major

> > > complications included anastomotic leak (13%),

> > atelectasis/pneumonia

> > > prolonging hospitalization (2%), recurrent laryngeal nerve

> > paralysis,

> > > chylothorax, and tracheal laceration (< 1% each). There were

five

> > > reoperations for mediastinal bleeding within 24 hours of THE.

> > > Intraoperative blood loss averaged 689 ml. Altogether, 78% of

the

> > > patients had no postoperative complications. Actuarial

survival of

> > the

> > > cancer patients mirrors that reported after transthoracic

> > > esophagectomy. Late functional results are good or excellent in

> > 80%.

> > > Approximately 50% have required one or more anastomotic

> > dilatations.

> > > With intensive preadmission pulmonary and physical

conditioning,

> > use

> > > of a side-to-side staple technique (which has reduced the

cervical

> > > esophagogastric anastomotic leak rate to less than 3%), and

> > > postoperative epidural anesthesia, the need for an intensive

care

> > unit

> > > stay has been eliminated and the length of hospital stay was

> > reduced

> > > to 7 days. We concluded that THE can be achieved in most

patients

> > > requiring esophageal resection for benign and malignant

disease and

> > > with greater safety and less morbidity than the traditional

> > > transthoracic approaches.

> > >

> >

>