Læknaneminn - 01.01.1983, Page 28

radiograph (fig. 1) showed a big tumor in
the left half of the thorax. arising from the
heart shadow. An airfilled space parallel
to the mediastinum and stretching to the
neck could also be seen, as marked by the
outlines. Since the patient wasn't able to
sit up, possible fluid Ievels could not be
determined. His condition remained
stable overnight.
The day after, the patient was feeling
better, so that further investigations
could be made. An X-ray esophagogram
with barium swallow (fig. 2) and a
computerized tomography of the thorax
showed the tumor and the airfilled space
to be an airfilled esophagus with an esop-
hageal tumor in the lowermost part. The
esophagus seemed to have pressed the
trachea, causing the symptoms before
mentioned.
An esophagoscopy was then perfor-
med. It showed a tumor situated 35 cm
from the upper teeth. A biopsy was taken
and after a pathological investigation it
proved to be an adenocystic carcinoma.
As a result of further questioning it was
discovered that the patient had earlier
felt that food, especially cold drinks,
somehow took a Ionger time than usual to
pass down the esophagus. This had for
the first time occurred around the end of
World War II. Around 1950 the esop-
hagus was dilated because of achalasia,
without perfect results. By and by the
symptoms increased until 1976, when the
patient was admitted to the hospital and
Heller's operation was performed, an
esophageal myotomy through a left
thoracotomy. In the four years following
the operation the patient seemed to be
completely cured. Then the previous
symptoms recurred and, as the patient
was not very fond of seeking medical
advice, they increased until the ad-
mittanoe to the department for heart
disease, as before mentioned.
After these investigations the patient
was moved to the department for thora-
cic surgery where, after suitable prepara-
tion, the following operation was per-
formed: The esophagus, including the
tumor, was resected (fig. 3). A pathologi-
cal investigation showed the margins to
be free of malignant cells. The stomach
was then prepared to reach the apex of
the thorax (fig. 4). A Coccher's man-
éuvre of the duodenum and a pylorop-
lasty were included in this, the purpose of
the pyloroplasty being that food later
would safely pass from the stomach to the
duodenum. The stomach was then sutur-
ed up into the apex of the right thorax.
Afterwards the esophageal stump was
anastomosed to the stomach end-to-side,
covering the anastomosis with peritone-
um of the stomach.
The patient was kept in the intensive
care unit for 5 days and was released from
the hospital 3 weeks after the operation.
The tumor (fig. 5) was an adenocystic
carcinoma (fig. 6) witli a small tumor of
squamous cell carcinoma. Although an
adenocystic carcinoma is quite usual in
the salivary glands, it has been described
only about 20 times in the esophagus.
without achalasia. A carcinoma of the
esophagus following achalasia, has twice
been described with the same clinical
presentation as in this case, plus two
additional times without the bullfrog
appearance, a squamous cell carcinoma
in all those four cases. An adenocystic
carcinoma has never before been de-
scribed as a consequence of achalasia, or
in connection with another kind of a
carcinoma.
Although cancer is a late consequence
of achalasia in only 3—5% of cases, it is
necessary for consideration, because of
the bad prognosis.
HEIMILDIR:
Christopher's Textbook of Surgery, 1982.
Muir's Textbook of Pathology. 1981.
Munnlegar upplýsingar skurölækna og mein-
fróöra.
Þakkir
Eg vil þakka Kristni Jóhannssyni lækni
sérstaklega fyrir að „lána mér sjúkling-
inn“ til að skrifa um. Afganginn af þökk-
unum fær Anna Lynn Parlett fyrir að
hjálpa mér með enskuna.
26
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