Presentation on theme: "History Of Oesophageal Surgery"— Presentation transcript:
1 History Of Oesophageal Surgery Mr Dipankar MukherjeeConsultant Upper GI & Laparoscopic surgeonQUEENS UNIVERSITY HOSPITAL UK
2 This talk is not about Basic science Non surgical treatment Benign surgery unless relevantEndoscopic therapy
3 Wide geographical variation United States5 cases perUnited Kingdom7-10 cases perIran, China, and Russiaover 500 cases perBlot WJ. Epidemiology of esophageal cancer. In Roth JA, RuckdeschelJC, Weisenburger TH, eds. Thoracic oncology. Philadelphia: WBSaunders, 1989;295
4 Rise of adenocarcinoma in Barretts… 30 years ago 10% of oesophageal cancers, it now representsapproximately 50% to 70% in the western world
5 Edwin Smith papyrus 3000 to 2500 BC ….The first report 1862Edwin Smith papyrus 3000 to 2500 BC….The first reportCase 28 of the 48 cases described in this work was entitled "A Gaping Wound of the Throat Penetrating the Gullet""...if thou examinest a man having a gaping wound in his throat, piercing through to his gullet; if he drinks water he ‘chokes’ (and) it comes out of the mouth of his wound; if it is greatly inflamed so that he develops fever from it, thou shouldst draw together that wound with stitching..."
7 Paul of Aegina (about 620-690)Alexandrian school Byzantine EraPaul of Aegina (about )Alexandrian schoolamputation of the breast for cancer, extirpation of the uterusTonsillectomytracheotomyRemoval of foreign body from oesophagussome of his descriptions of complicated and difficult operations have been little improved upon even in modern times
8 Challenges:The anatomic remoteness of the thoracic oesophagusPhysiologic challenge of intraoperative control of respirationhThe history of oesophageal surgery is the tale of men repeatedly losing to a stronger adversary yet persisting in this unequal struggle until the nature of the problems became apparent and the war was won.Emslie 1988Perspectives in the Development of Oesophageal Surgery
9 1633 Ambrose Parewhen the oesophagus was being sutured great care should be taken.
10 Cervical oesophagotomy for FB removal Hermann Boerhaave ( )post-mortem examinations to find the cause of fatal illnessesuse of the Fahrenheit thermometerThe syndrome that is named after him he described in 1724when Grand Admiral of the Dutch Fleet and Prefect of Rhineland Baron J van Wassenaer died soon after developing chest and abdominal pain after vomiting on a full meal.Boerhaave performed a post-mortem and identified an oesophageal rupture with spillage of gastric contents into the mediastinum (Boerhaave's syndrome1738 Goursaud and RolandCervical oesophagotomy for FB removal
12 Ignaz Semmelweis Vienna1848 Observation:Friend died of autopsy woundMeasurement:Physicians 10%Midwives 3%Hypothesis :"cadaveric particles."Smell not removed by hand washing, but calcium hypochlorite:Result:Ca(OCl)2 reduced puerperal fever death rate 12.4% to 1.27%.
14 Late 19th century Age of the German Titans ……Charite ` Berlin lineage Anesthesia 1846Langenbeck,Billroth, KocherCzerny,Polya, Mikulicz, SauerbruchThe pleasure of a physician is little, the gratitude of patients is rare and even rarer is material reward, but, these things never deter the student who feels the call within him"
15 Bernhard Rudolf Konrad von Langenbeck (1810 – 1887):Father of surgical residency Franko Prussian war of 1870–71Militär-ärztliche GesellschaftA forum of military surgeons of all nationality"father of the surgical residency". Berlina system whereby new medical graduates would live at the hospital as they gradually assumed a greater role in the day-to-day care and supervision of surgical patients.Among his most well-known "house staff" were such illustrious surgeons as Billroth and Emil theodore Kocher
16 …..And the great nephew of Langenbeck Theodor Billroth (1829-1894) First oesophagectomy in animalAdenoma carcinoma sequence 1855First laryngectomy1874Billroth I gasrectomy1881Prolonged apprenticeshipAnimal and cadaveric dissectionStudy of surgical literaturePolyaCzernyMikuliczsauerbruchHalstead
17 Theodor Kocher ( )Vincenz Czerny (1842 – 1916)1877,first “surgeon” to successfully resect a cervical oesophageal cancer
18 Johann von Mikulicz-Radecki 1850-1905 Skin tube 1886 oesophagoscopeListerismRespiratory studies
19 (Ernst) Ferdinand Sauerbruch..The Dark Lord.. German surgeon, Marburg, Zürich, München, Berlin , born in Bremen, died in BerlinSauerbruchs chamber 1904Limb prosthesisTuberculosis diet
20 William Halstead (1852-1922) John Hopkins William Halstead ( ) John Hopkins.. Brings experimental surgery and apprenticeship to AmericaStudent ofJohn Dalton a pioneering experimental physiologistTheodore billroth1889 technique of inguinal hernia repairearly 1890s radical mastectomy for breast cancer1892 he described ligation of the subclavian artery.Early 1900s he published on autotransplantationof the parathyroid gland..Fallen Hero
21 Story of anaesthesia AD 220 the Chinese surgeon Hua surgical anaesthesia.In 1526 Paracelsusether (which he knew as oleum vitreoli dulce) could quieten chickens andrelieve pain.In Birmingham in 1772 Priestley, a Unitarianminister, discovered nitrous oxide1825Charles WatertonPublished wanderings in South Americaaccurate account of curare.
22 1677 Robert hooke maintained life in dogs by bellows 1775 John Hunter two way air flow1846 Morton1853 simpsonMagill & RowbothamSauerbruchNegative pressure airtight chamberBrauer and PetersonCPAP Positive pressure chamberEndotracheal anaesthesia
23 …Penicillin sagaFleming A. On the antibacterial action of cultures of apenicillium with special reference to their use in theisolation ofB influenzae. BrJExp Pathol 1929;10:Chain E, Florey HW, Gardner AD, Heatley NG, JenningsMA, Orr-EwingJ, Sanders AG. Penicillinasa chemotherapeuticagent. Lancet 1940;ii:226-8.
24 FirstTransthoracic resection Endotracheal anaesthsia Oesophagectomy Franz Torek 1913FirstTransthoracic resectionEndotracheal anaesthsiaOesophagectomywithout reconstruction12 year survivalTorek F. The first successful case of resection of the thoracic portion ofthe esophagus for carcinoma. Surg Gynecol Obstet, 1913;16:614
25 Attempts at Reconstruction 1907 Dr. Cesar Roux (famous for the Roux-Y operation)use of jejunum as a substitute for the esophagus1911, Kellingfi rst successful case of cervical oesophagocolostomy usimg transverse colon1920, Kirschnersuccessful oesophago gastrostomy in the neck,pulling up a gastric pedicle through a subcutaneous route. in a patient who had swallowed lye and had a stricture
26 Between the great wars Ohsawa 1933 series of resections with immediateanastomosis‘Over a period of seven years, in a series of 101cases, he found 18 in which the growth involved the lower oesophagusor cardia and in which he was able to carry out resection and oesophago gastricanastomosis.Eight of these patients survived.
27 Between the great wars….. Grey Turner 1933: prodigious writer and a lone RangerTranshiatal ResectionVice-PresidentRoyal College of Surgeons of England,HunterianOrator and Hunterian Trustee.President of the Association of SurgeonsUnited States :Murphy OrationBalfour OrationOnly British surgeon to be awarded the Bigelow Medal.GREY TURNER AND THE EVOLUTIONOF OESOPHAGEAL SURGERY R. H. FRANKLIN F.R.!C.S. Ann. Roy. Coll. Surg. Engl. 1971, vol. 49)
28 End of the old era and the opening of a new one. 'Finally came the great day of my long-looked-for pilgrimage to Glasgow. In1901 my appendix had to be removed, As soon as I entered the operating theatre where Macewen was about to start work, it seemed like a new world to me;and I have never forgotten the tall, handsome figure standing by the basin washing his handswith the most punctilious care. To me it seemed wonderful that in those dayssomeone should come in and inoculate culture media from beneath the surgeon'sthe surgeon'snails.'It was not that the work in Newcastle-upon-Tyne was of a poor standard, forI yield to no one in my esteem for Rutherford Morison. But our theatre was not a sacred place, withoutany of the ritual associated with a surgical operation as we know it to-day, oras Macewen knew it and practised it in those days. All our sterilisation was byimmersion in strong antiseptics, nothing was boiled and the arrangements wereof the simplest.
30 Grey Turner 1933 successful Transhiatal resection Radicalism'better todo too much than too little'careBetter a livingproblem than a dead certaintyPatient focus'Gentlemen, you are probably saying to yourselves this is only anAppendicectomy -but I can assure you that this is the most important operation being carried out to-day-for this particular patient.‘decimalization and metrication.vision'One day they will operate on the heart-mark my words';'We shall never overcome cancer by surgery, it will be by something we shall injectGrey Turner successful Transhiatal resection
31 Following Grey turner & Ohsawa 1938, Adams and Phemisterlower oesophagectomy and immediate oesophagogastrostomy through open thoracotomy1933,Osawa at Kyoto UniversityFirst successful cases worldwide of the same procedureGarlock 1944Sweet1948worldwide leaders of oesophageal surgery in the middle of the twentieth century, succeeded in oesophago gastrostomy in the thoracic cavityOshawas left thoracoabdominal technique remained a dangerous procedure for mid oesophageal tumoursGARLOCK, J. H. (1944) Surg. Gynec. Obstet. 78, 23.
32 Status of surgical treatment for esophageal cancer worldwide, 1965 T. Kakegawa, MD · H, Fujita, Gen Thorac Cardiovasc Surg (2009) 57:55–63Cases of resection (%) Operative mortality (%) Cases of 5-year survival (%)Garlock (39.6%) % (21.2%)Sweet (52.1%) % (12.1%)Ellis (27.0%) % (17.2%)Logan (59.7%) % (23.0%)Petrov (19.0%) % (11.5%)Berezov (29.2%) %Wu (40.1%) % (23.7%)Kuo (12.7%) %Lortat-Jacob 308 (54.8%) % (6.2%)
33 …..Joining up the gullet : the War years folowers of ohsawa and Grey Turner 1937 Nissen First successful anastomosisreported a case of transthoracic cardio-oesophagealresection for penetrating ulcer, and this was probably the first successfulanastomosis in Europe and the Americas.1938 Adams and Phemister : First one stage resectionbut most oesophageal surgeons continued to practise the twostageprocedure,ADAMS, W. E., and PHEMISTER, D. B. (1938) J. thorac. Surg. 7, 621.1942 Brock: The first followercarried out a successfulone-stage resection and anastomosis for a patient with a large myoma.BROCK, R. C. (1942) Brit. J. Surg. 30, 146.1945 Vernon Thompson: First UK successThe first patient with a carcinoma to be treated successfully in this way in the UKTHOMPSON, V. C. (1945) Brit. J. Surg. 32, 377.
35 1946, The watershed: Transthoracic resection Lewis I. Hunterian lectureThe surgical treatment of carcinoma of the oesophagus withspecial reference to a new operation for growths of themiddle third.Br J Surg, 1946;34:18Inspiration to be a doctor severe attackof acute appendicitis at the age of I2-beingoperated upon by David Ellis of Aberystwyth1939First successful pulmonary embolectomy in the UK
36 Olympus: Going Where no Camera has Gone Before The Pain in the Butt CameraOlympus gastrocamera 1960
37 Ronald Belsey TO Fistula Zenkers Diverticulum Antireflux procedure Belsey R. Reconstruction of the esophagus with left colon. J Thorac Cardiovasc Surg 1965;49:33-55.Zenkers DiverticulumThe American Association for Thoracic Surgery in 1966, emphasized a dysfunction of the cricopharyngeal muscle as the underlying cause series of 45 patients, the majority of them treated with myotomy and diverticulopexyAntireflux procedureBelsey Mark IVCancer “cure is an accident"
38 1976 :Total oesophagectomy McKeown KC. Total three stage oesophagectomy for cancer of the oesophagus. Br J Surg, 1976;63:259
39 Poor results :Earlam R, Cunha-Melo Jr. Oesophageal squamous cell carcinoma. 1.A critical review of surgery. Br J Surg, 1980;67:381Muller JM, Erasmi H, Stelzner M, Zieren U, Pichlmaier H. Surgi calTherapy of Oesophageal Carcinoma. Br J Surg, 1990;77:845
40 Rt Vs Left Thoracotomy Similar results mortality and survival Launois P, Lygidakis C, Malledant G. Results of the surgical treatmentof carcinoma of the esophagus. Surg Gynecol Obtet, 1983;156:753Similar results mortality and survivalreflux more in left
41 Total vs Subtotal stricture more in cervical anastomosis Chasseray VM, Kiroff GK, Buard JL, Launois B. Cervical or thoracicanastomosis for esophagectomy for carcinoma. Surg Gynecol Obstet,1989;169:55stricture more in cervical anastomosis
43 Anastomosis:Staples or handsewn Stricture more in stapled
44 How radical is radical? Skinner DB, Dowlatashy KD, DeMeester TR. 80 patientsradical Enbloc resection9 (11%) 30 day mortalityPotentially curablecancer of the esophagus. Cancer, 1982;50:2571Wong J.Esophageal resection for cancer: the rationale of currentpractice. Am J Surg, 1987;153:18
45 20 years in Chiba University Seo and OsawaJapan surgical society 1932Review of world literature before 1942worldwide incidence of operative mortality up to 1932144 (95.4%) of the 155 patientsNo sucessful reconstructionHiroshi AkiyamaNakayama Japan Surgical Society 1951incidence of operative mortalitywas only 5 (16.6%) of 30 patients who underwent subtotalesophagectomy followed by esophagogastrostomythrough a subcutaneous route for cancer in the upperor middle thoracic esophagus.
46 Three Japanese masters 1951-1966 Nakayama and Sato Chiba University : Multistage procedureThe operativemortality rate oesophagectomy% of 30 patients% of 2053 patientsKatsura at Tohoku University8/15 55% mortality using positive pressure0/21 0% using endotrachaeal anaesthesiaAkakura at Keio University, 1966 JATS presidential lecture :average operative mortality rate in Japan was 15.6% ,861 of 5327average 5-year survival rate was 12%
47 Problems to be resolved in oesophageal surgery Akakura keio University :Problems to be resolved in oesophageal surgery1. Causes of short-term mortality1) Incorrect indication for surgery2) Incorrect adoption of surgical procedures3) Incorrect surgical maneuverPostoperative complicationsa. Anastomotic leakageb. Pulmonary complication(s)c. Circulatory failure2. Causes of long-term mortality1) Non-curative surgerya. Incomplete resection of a local tumorb. Lymph node metastasisc. Distant organ metastasis2) Malnutrition3) Diseases of the elderly
59 11 years of Laparoscopic oesophageal surgery 1991, Dallemagne et al and Geagea Laparoscopic fundoplication1991 Shimi et al Laparoscopic esophageal myotomy.1993, Cuschieri et aloutcome of Laparoscopic fundoplication> 100 patients multicenter study
60 Antoon Lerut LeuvenStudent ofRonald Belsey BristolJames Luketich philadelphia
61 Staging : Evolution in the west CT and EUSTio TL, Cohen P, Coene PP.Endosonography and computed tomographyof esophageal carcinoma.Gastroenterology, 1989;96:1478Grimm H, Soehendra N, Hamper K.Contribution of endosonographyto preoperative staging in esophagealand stomach cancer. Chirurg,1989;60:684 Gastroenterology, 1989;96:1478Rankin SC, Taylor H, Cook GJ, Mason R.Computed tomographyand positron emission tomography in the pre-operative staging of oesophageal carcinoma. Clin Radiol, 1998;53:659ThoracoscopyKrasna MJ, Reed CE, Jaklitsch MT. Thoracoscopic staging of esophageal cancer: a prospective, multiinstitutional trial. Cancer and LeukemiaGroup B Thoracic Surgeons. Ann Thorac Surg, 1995;60:1337
62 MDTAjani JA. Current status of new drugs and multidisciplinary approachesin patients in patients with carcinoma of the esophagus.Chest, 1998;113:112S
63 Collaboration not competition Ando N, Iizuka T, Kakegawa T.A randomized trial of surgery wit hand without chemotherapy for localized squamous carcinoma of the thoracic esophagus. J Thorac Cardiovasc Surg, 1997;114:205Teniere P, Hay JM, Fingerhut A.Postoperative Radiation does no t increase survival after curative resection for squamous cell cancer ofthe middle and lower oesophagus as shown by a multicenter controlled trial. Surg Gynecol Obstet, 1991;173:123Leprise E, Etienne PL, Meunier B. A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localizedsquamous cell carcinoma of the esophagus. Cancer, 1994;73:1779
64 Chemoradiation increased survival Walsh TN, Noonan N, Hollywood D.A comparison of multimodaltherapy and surgery for esophageal adenocarcinoma.N Engl J Med 1996;335:462Forastiere AA, Orringer MB, Perez-Tamayo C, Urba SG, ZahurakM. Preoperative chemoradiation followed by transhiatal esophagectomy for carcinoma of the esophagus: final report.J ClinOncol, 1993;11:1118
67 Please do not walk away when you stumble onto it… Introduction of modern surgical techniques should lead to a paradigm shift in the mindset of the referring cliniciansThings do not change; we change
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