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The AA. report a clinical case of rare oesophageal pathology: the leioomyosarcoma sole case on 200 oesophageal neoplasms that they have observed. The clinical likeness with oesophageal carcinoma and the complete superimposition of reports that have been obtained in this case with instrumental examinations respect to the oesophageal carcinoma, didn't permit to do the diagnosis of histotype, while this diagnosis could be done only after the preparation of an histopathologic preparation. The patient who was operated on for superior polar esophago-gastrectomy, after 18 months is in good general conditions. THe AA. draw their conclusions after a short discussion. We must show in these paragraphs the particular macroscopic form of neoplasm that they have observed and the great difficulty of a diagnosis of leimyosarcoma without an histopathologic preparation. Agreeing with the most part of other Authors, they point out that the best therapy for these forms is surgical therapy.

Between november 1964 and december 1982, 102 patients were operated upon for the treatment of carcinoma thoracic esophagus. The philosophic objectives were to restore promptly the ability to swallow and to achieve a worthwhile survival period. To fulfill these requirements wide excision of the growth and immediate esophagogastrostomy were performed through a combined abdominal and right thoracic approach. In higher thoracic growths the Authors added a cervical phase. The resectability rate was 74% and the overall hospital mortality rate was 19,6%. Anastomotic leaks occurred in 10 patients (9,8%) with fatal outcome in 6. Pre- and postoperative care (particularly hyperalimentation and intensive respiratory therapy) and use of mechanical devices reduced the operative mortality rate to 8,1% between 1976 and 1982 without deaths in the last 16 patients. Very satisfactory palliation was achieved in 80% of the patients who survived the standard esophagogastrectomy. These patients enjoyed uncomplicated oral alimentation for the remainder of their lives. Despite there has been considerable improvement in operability and resectability rates and in survival of resection as compared to past years, long term results of treatment of carcinoma of the esophagus continue to remain disappointingly low. Overall survival rate at 5 years was 10,2% in this report. The stage of the disease influenced significantly survival: curative as opposed to palliative resections demonstrated a marked difference in 5-year survival (28,2% vs 2,8%). Long-term survival of patients with carcinoma of the esophagus will probably not improve until early diagnosis is possible. Therefore esophagogastrectomy should be the treatment of choice until other forms of therapy prove superior to it both in terms of palliation and long-term survival rate.

Palliative substernal gastric bypass was performed in 20 patients with far-advanced, obstructing carcinoma of the thoracic esophagus between the years 1978 and 1982. In 18 patients the thoracic esophagus was bypassed using the stomach brought to the neck by substernal route for anastomosis to the proximal end of the divided cervical esophagus. The thoracic esophagus was completely excluded in 10 patients; the tumor-bearing segment of the esophagus excluded formed a small and asymptomatic mucocele with time. The Kirschner-Ong technique with the additional step of Roux-en-Y jejunal anastomosis to the intra-abdominal esophagus was used to provide drainage of esophageal secretions in 8 patients with tracheoesophageal invasion or impingement, for fear of imminent esophagorespiratory fistula; in three of these patients a radiation therapy was subsequently administered. In two patients an isoperistaltic gastric tube formed from the greater curvature and brought to the neck substernally was used for esophageal bypass. Anastomotic leakage occurred in 3 patients (15%). The thirty day operative mortality was 10 per cent (2/20) and the mean survival time was 10 months. The palliation afforded was excellent in all survivors with restoration of the ability to swallow a normal diet until the time of death. The authors believe that a simple one-stage bypass of the esophagus using the stomach substernally is an effective alternative to esophageal intubation, prolonged radiation therapy or colon bypass in achieving palliation with an acceptable morbidity and mortality in a high risk patient group.

The authors analyse 50 sutures by hand and 50 by stapling device in oesophagocardial surgery, and compare them as to time of performance, number and quality of complications and influence on the protraction of stay in hospital after operation. The conclusions indicate the sutures by device as the most reliable and safe, susceptible to supplant, although not totally, the techniques by hand.

In the light of three cases of esophageal carcinoma developing on a pre-existing idiopathic megaesophagus the authors examine etiopatological, clinical and terapeutic problems related to this association. They believe that carcinoma of the esophagus tends to be a complication of cardiospasm in patients inadequately treated for the primary condition. Early diagnosis and an adequate Heller operation for cardiospasm will lessen the chance of cancer developing in megaesophagus with stasis. When finally diagnosed, this variety of esophageal carcinoma has an extremely poor prognosis. An even more important claim upon the clinician is to be alert to the hazards of continued stasis in megaesophagus and to devise earlier techniques of recognition, including more frequent recourse to biopsy during esophagoscopy.

An experience with 16 patients with respiratory tract fistula (RTF) related to carcinoma of the esophagus is presented. The malignant fistula was present at the time of initial presentation and/or before any therapeutic intervention in 11 patients, and developed either during or following a course of radiation therapy in 5 patients. Bronchoscopy examination in 8 patients prior to RTF development showed tracheobronchial invasion or impingement in all. The patients were divided in five groups according to the treatment received. One patient received no specific therapy although was fed via nasogastric tube. Three patients had a feeding gastrostomy. Four patients underwent insertion of a Celestin tube. Three patients were submitted to esophageal exclusion with combinations of cervical esophagostomy, feeding gastrostomy and ligation or complete division of the gastroesophageal junction; drainage of the excluded esophagus was provided by a red rubber catheter. Five patients received by-pass operation: four had Kirschner-Ong operation with gastric by-pass placed substernally and distal esophagus anastomosed to a Roux-en-Y jejunal loop; in one patient an isoperistaltic gastric tube brought to the neck substernally was used for esophageal by-pass. These patients had, by far, the best palliative results with complete relief of their respiratory tract symptoms and restoration of the ability to eat and drink. Substernal gastric by-pass of the RTF is therefore advocated if the general conditions of the patient are improved with the institution of parenteral hyperalimentation and antibiotic therapy.