Page 2 P H Y S I O T H E R A P Y December, 1968 P a p e r d e li ve r ed a t P o s t - R e g i s t r a u o n C o u r s e , S .A .S .P . N a t i o n a l C o u n c i l M e e t i n g , P o r t E l i z a b e t h , M a y , 1968. The Clandestine Cancer Carcinoma of the Oesophagus M r . D . S. P R O C T O R , M . B . C H . B . ( C A P E ) , F . R . C . S . ( E N G . ) , D . C . H . , R . C . P . & S. ( L O N D . ) In t hi s c o u n t r y t h e r e is o n e o f t h e h i g h e s t i n c i d e n c e s o f O e s o p h a g e a l C a r c i n o m a in th e w o r l d . I h a v e r e ce nt ly c o m ­ p l e t e d a s u r v e y o f t h e r e s u l t s o f m a n a g e m e n t o f O e s o p h a g e a l C a r c i n o m a o v e r f o u r y e a r s a t L i v i n g s t o n e H o s p i t a l u p to th e e n d o f 1967. 523 ca s es w er e t r e a t e d p e r s o n a l l y . M o s t o f o u r ca s es c o m e f r o m t h e T r a n s k e i a n d it is v er y i n t e r e s t i n g t h a t it s h o u l d be c o n c e n t r a t e d in th i s w a y in th i s a r e a . It is this e x t r a o r d i n a r y h i gh in c i d e n c e t h a t h a s s t i m u l a t e d t he n ece ss it y a n d d e s i re t o i n v e s t i g a t e e t i o l o g y f r o m th e p o i n t o f view o f e p i d e m i o l o g y , g e o l o g y a n d s oc ia l h a b i t s. W e a t t h e L iv i n g s t o n e H o s p i t a l h a v e e s t a b l i s h e d a l i ai so n wit h B a n t u C a n c e r R e g i s t r y in E a s t L o n d o n , w h o a r e s t u d y ­ in g t he se a s p e c t s . W e u n d e r t a k e a d i a g n o s t i c clini c twice m o n t h l y , a t B u t t e r w o r t h , w h ic h is o u r c o n t r i b u t i o n t o this r e s e a r c h p r o j e c t . A n u m b e r o f v er y i n t e r e s t i n g fa ct s h a v e e m e r g e d f r o m t h i s w o r k . W e h a v e f o u n d t h a t th i s is in fa c t a sl o w - g r o w i n g C a r c i n o m a . T h i s m a y s e e m r a t h e r c o n t r a ­ d i c t o r y w h e n o n e c o n s i d e r s t h a t th e d i se as e in S o u t h A f r i c a is 100 p e r c e n t f a t a l . H e r e we h a v e in e a r l y s t a g e s a re la ti ve ly i n n o c u o u s C a r i n c o m a w h i c h is so re le nt le ss ly l et h al . W h y ? W e h a v e be en p r e o c c u p i e d w i t h t h is c h a l l e n g e c o n t i n u o u s l y , b u t a r e still a l o n g w a y f r o m h a v i n g a n s w e r e d it. N e v e r t h e l e s s c o n s i d e r a b l e p r o g r e s s h a s b e e n ac h i e v e d . It is th i s k n o w l e d g e , w h i c h I c a n n o t d i s c u s s t o d a y , w h i c h h a s g u i d e d o u r po li cy o f m a n a g e m e n t , w h i c h is t h e s u b j e c t o n w h i c h I sh a ll s p e a k . E v i d e n c e f o r m y e a r l i e r r e m a r k s o n s l o w n e s s o f g r o w t h m a y be se en in t h e f o l lo w in g c a s e : A p a t i e n t p r e s e n t e d in 1957, w a s e x a m i n e d by B a r i u m M e a l a n d p a s s e d as n o r m a l . H e r e t u r n e d in 1959 w h e n B a r i u m S w a l l o w s h o w e d a m o d e r ­ a t e d ef ec t in t he o e s o p h a g u s . H e w as still a b l e t o s w a l l o w fa irly well a n d d e c l i n e d t r e a t m e n t . T w o y e a r s l a t e r he w as b a c k a g a i n w i t h d y s p h a g i a . R a d i o l o g i c a l l y t h e r e w a s still a v e r y a d e q u a t e l u m e n t o t h e o e s o p h a g u s b u t t h e de f ec t h a v i n g e x t e n d e d s o m e w h a t . H e r e f u s e d t r e a t m e n t a g a i n . T w o y e a r s l a t e r he c a m e b a c k f o r a n o t h e r B a r i u m S w a l l o w * I* V Fig. 1. Two operative specimens. (a) A m a l i g n a n t u l c e r o f t h e o e s o p h a g u s m e a s u r i n g 7 m m . in d i a m e t e r . T h i s is o n e o f th e s m a ll e s t a n d ea rl ie st c a r c i n o m a s e n c o u n t e r e d a t th e L i v i n g s t o n e H o s p i t a l . (b) A n a d v a n c e d c a r c i n o m a wit h a l m o s t c o m p l e t e d e s t r u c ­ t i o n o f a l o n g l e n g t h o f o e s o p h a g u s . s h o w i n g a n a l m o s t c o m p l e t e o b s t r u c t i o n . By thi s t i m e he h a d n u m e r o u s p u l m o n a r y m e t a s t a s e s , a n d w a s b e y o n d t r e a t m e n t . It t o o k five y e a r s t o r e a c h t h a t p a r t i c u l a r stage. In a s l o w - g r o w i n g t u m o u r like this, o b v i o u s l y t h e r e is a p r o c e s s w h ic h is u n d e r w a y f o r a n u m b e r o f y e a r s w i t h o u t th e p a t i e n t b e i n g a w a r e o f it in a n y w a y w h a t s o e v e r . T h e first s y m p t o m o b v i o u s l y , is difficulty in s w a l l o w i n g solid f o o d p ar t i cl es . T h i s d y s p h a g i a is a c c o m p a n i e d l a t e r by the difficulty in m a n a g i n g t h e p a t i e n t ’s o w n s e c r e ti o n s , a n d the i n a b i l i t y t o s w a l l o w fluids a d e q u a t e l y . T h i s p r o g r e s s e s to a n a l m o s t c o m p l e t e o b s t r u c t i o n an d by th i s t i m e t h e y c a n n o t m a n a g e a n y t h i n g . F o o d a n d fluids a c c u m u l a t e in t h e p r o x i m a l o e s o p h a g u s , a n d spills o v e r i n t o t h e r e s p i r a t o r y t r a c t . T h i s is w h e r e t h e i m p o r t a n c e o f p h y s i o t h e r a p y t o th e r e s p i r a t o r y sy s t e m b e c o m e s p a r a ­ m o u n t . T h e s e e x a m p l e s ( Fi gs .) i l l u s t r a t e t h e e x t e n t a n d r a v a g e s o f thi s d i se a se : T h e t u m o u r m a y s t a r t a s a s m a l l ul ce r, n o m o r e t h a n se v er a l m i l l i m e t e r s in d i a m e t e r w h i c h is t h e ea r l i es t g r o w t h see n a t th e L i v i n g s t o n e H o s p i t a l ( Fi g . l a ) . T h i s in J a p a n w o u l d be r e g a r d e d as a v er y a d v a n c e d les ion . T h e u l c e r is s m a ll b u t is s u r r o u n d e d by s u b m u c o u s e x t e n s i o n w hi ch m a y h a v e p r o g r e s s e d t o q u i t e a c o n s i d e r a b l e e x t e n t . T h e c a n c e r p r o g r e s s e s t o a l a r g e r ul cer w i t h d e e p e r e x c a v a t i o n in t h e c e n t r e . T h i s e x c a v a t i o n e x t e n d s i n t o t h e m e d i a s t i n u m b e y o n d t h e o e s o p h a g u s . A t thi s st a g e , t hi s t u m o u r c a n be a l m o s t e n t i r e l y s i l e n t ; sile nt, s i n i s t e r a n d q u i t e r ut hl e ss . T h e u l ce r e x t e n d s a r o u n d t h e wall o f t h e o e s o p h a g u s , b e ­ c o m i n g c i r c u m f e r e n t i a l a n d o n e c a n i m a g i n e n o w h o w difficult it is t o s w a l l o w a n y t h i n g b u t t h e t h i n n e s t o f l i qu i d in t h a t n a r r o w p a s s a g e ( Fi g . l b ) . L a r g e t u m o u r s , m o r e f u n g a t i n g t h a n u l c e r a t i n g m a y r e t r a i n a s u p r i s i n g l y l ar ge l u m e n in t h e o e s o p h a g u s ( Fi g. lc) . T h e s e c a r c i n o m a s f r e ­ q u e n t l y b e h a v e li k e a n ice b er g . W e see so m u c h in t h e o e s o ­ p h a g u s i t s e l f wh il e t h e r e is a n o t h e r 4 o r 5 t i m es th i s size b e y o n d th i s s t r u c t u r e , in t h e m e d i a s t i n u m ( Fi g. 2). Fig. 2. Late oesophageal carcinoma with extension into the lungs. (a) L a t e r a l X - r a y o f t h e ch e s t d e m o n s t r a t i n g a l ar g e l u n g a b s c e s s c a u s e d by t h e fi stula s e en in (b ). (b) T h e g r o w t h wit h c o m p l e t e d e s t r u c t i o n o f t h e o e s o p h a g u s w i t h a p r o b e d e m o n s t r a t i n g a l ar g e fistula. T h e o e s o p h a g u s m a y b e c o m e e n t i r e l y d e s t r o y e d by t he c a r c i n o m a , w h i c h r e p l a c e s it c o m p l e t e l y , e x t e n d i n g b e y o n d i n t o t h e m e d i a s t i n u m , l y m p h g l a n d s , p e r i c a r d i u m , l u n g a n d b r o n c h i a n d all o t h e r s t r u c t u r e s in t h e m e d i a s t i n u m e x ce pt t h e a o r t a ( Fi g s . 3 a n d 4). D i s t a n t m e t a s t a s e s t o b r a i n a n d s k u l l h a v e been se en , bu t a r e r a r e . L iv e r s e c o n d a r i e s ar e m o r e c o m m o n , b u t n e v e r t h e l e s s n o t f r e q u e n t l y se en . H a v i n g e v i d e n c e o f t h e v is c io us a d v a n c e s o n t h e b o d y m a d e by thi s c a n c e r , it b e c o m e s c l e a r w h y it is so i m p o r t a n t t o p a l l i a t e t h e m in s o m e w a y o r a n o t h e r . H o w d o we m a n a g e s u c h a R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) December, 1968 P H Y S I O Fig. 3. X - r a y s o f t h e ch es t o f a p a t i e n t wi th a n o e s op h ag o- m e d i a s t i n a l fistula. (a) B a r i u m M e a l d e m o n s t r a t e s t h e fistula. (b) T h e m e d i a s t i n a l a b s c e s s r e s u l t i n g f r o m t hi s fistula. T H E R A P Y Page 3 get t h e m in a n d o u t o f h o s p i t a l , as q u i c k l y as p o ss i b l e , b a c k t o t h e i r fam ili es , e n j o y i n g a b o v e all, c o m p l e t e g a s t r o n o ­ m i c n o r m a l i t y . O u r p o l i c y in t h e last f o u r y e a r s h a s a l w a y s b ee n t o resect t h e t u m o u r w h e r e p o ss ib le . T h i s h a s be en s u b j e c t to c ri tic is m w h i c h o n su pe rfi cia l a p p r a i s a l is p o s s i b l y j u st if ie d. W h a t p u r p o s e is t h e r e in a t t a c k i n g w i t h a m a j o r o p e r a t i o n l a s ti n g 3-6 h o u r s , a t u m o u r w h i c h i n e v i t a b l y will ki ll th e p a t i e n t in se v er a l m o n t h s a f t e r s u r g e r y ? T h e a n s w e r is p r o v i d e d by th e p a t i e n t , w h o is t h e final a r b i t e r . S w a l l o w i n g is r e s t o r e d to n o r m a l a n d full di e t is e n j o y e d un t i l d e a t h . O n l y m a j o r s u r g e r y h a s a c h i e v e d th i s in o u r series, w h i l e lesser d eg r ee s o f p a l l i a t i o n a r e a c h i e v e d by m o r e c o n s e r v a t i v e m e a s u r e s . O u r i n t e n t i o n is t o re sect all c a s e s w h e r e p o s s i b l e . H o w e v e r , we find t h a t o n l y o n e in five c o m e t o r e s e c ti o n . T h e o t h e r s ar e f ar t o o a d v a n c e d o r th ey h a v e se v er e p u l m o n a r y c o m ­ p l i c a t i o n s p r e c l u d i n g a t t e m p t s a t a n y k i n d o f m a j o r s u r g e r y . W e a r e n o t d i s t u r b e d by th e e x t e n t o f t h e g r o w t h lo cally, o r w h e t h e r t h e t r a c h e a o r a b r o n c h u s m a y be in v o l v e d , p r o v i d e d t h e r e is n o d i r e c t fi stula (Fig . 5). W e m a y excise a c u f f o f t h e b r o n c h u s a n d r e p a i r it, o r l u n g o r p e r i c a r d i u m , in r e s e c ti n g t h e t u m o u r , d e p e n d i n g o n t h e s t r u c t u r e s i n v a d e d . F i g . 4. M e d i a s t i n a l in vasion by th e a q u a m o u s c a r c i n o m a . (a) T h e t r a c h e a , a o r t a a n d g r e a t vessels o f t h e n e c k c o m ­ pl et el y e n c a s e d i n t he g r o w t h . (b) T h e h e a r t s t u d d e d w i t h m e t a s t a t i c d e p o s i t s o f s q u a m o u s c a r c i n o m a o r i g i n a t i n g i n t h e o e s o p h a g u s . m a l i g n a n c y , p a r t i c u l a r l y w h e n it is so f a r a d v a n c e d ? T h e r e a r e a n u m b e r o f m e a s u r e s a v a i l a b l e t o us, viz. s u r g e r y , r a d i o t h e r a p y o r s i m p l y as a final r e s o r t , by i n t u b a t i o n . W e a i m t o a b b r e v i a t e t r e a t m e n t as m u c h as p o s s i b l e b e c a u s e t h e y d o n o t h a v e v er y l o n g t o live a n y w ay . T h e a i m is to F i g . 5. T w o op e r a t i v e spe ci m en s. (a) S h o w i n g m e d i a s t i n a l g l a n d s a n d s e g m e n t o f l u n g r e m o v e d w it h th e t u m o u r . (b) M e d i a s t i n a l a n d s u b c a r d i n a l g l a n d s r e m o v e d w i t h t he t u m o u r . O e s o p h a g o g a s t r e c t o m y is d o n e in a si n g l e s ta ge . T h e o p e r a t i o n i ts el f w a s first d ev i s ed by L ew is in 1946. A t t h e L i v i n g s t o n e H o s p i t a l a fe w m o d i f i c a t i o n s o f th i s o p e r a t i o n h a v e b e e n d e vi s ed e.g., t h e t e c h n i q u e o f a n a s t o m o s i s a f t e r b r i n g i n g t h e s t o m a c h u p f r o m t h e a b d o m e n . A b o u t h a l f t he s t o m a c h is re se c te d , r e c o n s t i t u t i n g th e les ser c u r v e , a n d c o n t i n u i t y is r e s t o r e d by a n a s t o m o s i s b e t w e e n th e s t o m a c h a n d t he o e s o p h a g u s . T h i s h a s b e e n t h e g r e a t f a i l u r e o f t h e o p e r a t i o n w h i c h h a s n o t b e e n p o p u l a r b e c a u s e o f t h e h ig h o p e r a t i v e m o r t a l i t y . T h i s o p e r a t i v e m o r t a l i t y h a s be en c a u s e d la rg el y by l e a k a g e a t th e a n a s t o m o s i s . By m e a n s o f a n “ i n k w e l l ” a n a s t o m o s i s ( Fi g s . 5 & 6) de v i s ed at L i v i n g s t o n e H o s p i t a l , t h is c o m p l i c a t i o n n o l o n g e r exis ts. H o w e v e r , b e i n g a m a j o r o p e r a t i o n , o t h e r m a j o r c o m p l i c a t i o n s m a y ar is e. T h e r e is a m o r t a l i t y r a t e , as se en in T a b l e I I . W e h a v e n o w r e d u c e d t hi s f r o m 20 p e r c e n t t o 12 p e r c e n t in 1967 /6 8, in t h e la st 4 8 ca s es . T h i s c o m p a r e s f a v o u r a b l y w i t h o t h e r f ig ure s el s e w h e r e . T h e a v e r a g e m o r t a l i t y r a t e in l i t e r a t u r e f r o m t h e U n i t e d S t a t e s , E n g l a n d a n d t h e C o n t i n e n t is a b o u t 20 t o 25 p e r c e n t . I n J a p a n t h e y c l a i m a b o u t 14 p e r c e n t o p e r a t i v e m o r t a l i t y w i t h o n e s t a g e o e s o p h a g o ­ g a s t r e c t o m y . W h e r e th i s r e d u c t i o n h a s b e e n a c h i e v e d , a n d R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y December, 1968 Fig. 6 . A diagrammatic representation o f the “ inkwell” anastomosis. I sa y th i s in c o m p l e t e si n c er i t y , is t h e r e c o g n i t i o n o f th e e x t r e m e i m p o r t a n c e of, p r e - o p e r a t i v e a n d p o s t - o p e r a t i v e c a r e . N o t o n l y t h e p a t i e n t ' s n u t r i t i o n , w h i c h is u s u a l ly p o o r , is o f i m p o r t a n c e . W e u s u a l l y m a n a g e t o get t h e p a t i e n t t o p u t o n a few p o u n d s in w ei g h t d u r i n g his s t a y in h o s p i t a l . M o s t i m p o r t a n t o f all is i n t e n s i v e c a r e t o t h e r e s p i r a t o r y sy s t e m b e f o r e a n d a f t e r o p e r a t i o n . P o s t u r a l d r a i n a g e , in t en si v e r e s p i r a t o r y p h y s i o t h e r a p y is m a n d a t o r y , if th e s e p a t i e n t s a r e t o s u r v i v e a m a j o r o n s l a u g h t s u c h as we inflict. T h e p a t i e n t s r e q u i r e i n t e n s i v e e d u c a t i o n , b e i n g t a u g h t h o w t o b r e a t h e a n d b r e a t h e a d e q u a t e l y , a n d t h e y a l s o h a v e t o be t a u g h t h o w t o c o u g h p r o d u c t i v e l y . T h e p a t i e n t is i n c li ne d t o i m i t a t e a c o u g h w i t h o u t a c t u a l l y p r o d u c i n g it. T h e y h a v e to be t a u g h t h o w t o d o it effectively. W h e n th i s es s e n t i a l r e q u i r e m e n t is fu lly r e c o g n i s e d , o p e r a t i v e m o r t a l i t y f r o m r e s p i r a t o r y c o m p l i c a t i o n s will b e r e d u c e d t o a m i n i m u m . F ig . 7 s h o w s a g r o u p o f p o s t - o p e r a t i v e p a t i e n t s , i n d i c a t i n g a b d o m i n a l a n d t h o r a c i c in ci si o n s . T h e i r p l e a s u r e a t b e i n g a b l e t o e a t a n d e n j o y o n c e m o r e , a full d ie t, is e v i d e n t o n t h e i r faces. I f we a r e n o t a b l e t o p e r f o r m a n o e s o p h a g o - g a s t r e c t o m y , we h a v e t o be a b l e t o of fer s o m e t h i n g else. I n m y e x p e r i e n c e I h a v e n o t yet e n c o u n t e r e d a n y t h i n g a s m i s e r a b l e a n d m o r e d i s t r e s s i n g t h a n t o see a p a t i e n t d y i n g o f a n u n t r e a t e d O e s o p h a g e a l C a r c i n o m a . S o m e t h i n g h a s t o b e d o n e f o r t h e m , i f o n l y t e m p o r a r i l y . W h e n t h e y a r e n o t fit f o r a t h o r a c o t o m y t h e n e x t p r o c e d u r e a v a i l a b l e is a n oeso- p h a g o c o l i c b y- pas s. A s e g m e n t o f c o l o n is i s o l a t e d a n d p l a c e d b e t w e e n t h e ce r vi ca l o e s o p h a g u s a n d s t o m a c h . T h e a s c e n d i n g c o l o n a n d p e r h a p s t e r m i n a l i l e u m w e r e u s e d i ni tially . T h i s is i s o l a t e d f r o m t h e g a s t r o - i n t e s t i n a l t r a c t . C o n t i n u i t y is r e - e s t a b l i s h e d b y r e j o i n in g t h e p r o x i m a l i le u m a n d c o l o n . T h e is o l a t e d s e g m e n t is t r a n s p l a n t e d o n a v a s c u l a r p e d i c a l u si n g t h e m i d d l e c o li c a r t e r y , w h i c h r e m a i n s i n t a c t . T h i s c o l o n w as b r o u g h t u p a n t e s t e r n a l l y , i.e. s u b c u t a n e o u s l y . Fig. 7. A group o f patients convalescing immediately after oesophago-gastrectomy. T h e c o l o n o r t e r m i n a l i le u m is t h e n a n a s t o m o s e d t o the o e s o p h a g u s in t h e n ec k a n d t o t h e s t o m a c h in t h e a b d o m e n . O u r r e s u l t s wi t h t h is w e r e d i s a s t r o u s — o t h e r w o r k e r s c l a i m i n g s a t i s f a c t o r y r es ul ts . T h e r e a s o n f o r t h is f a i l u r e we a t t r i b u t e d t o t h e fa c t t h a t t h e c o l o n c o u l d n o t m a i n t a i n t h e b l o o d su p p l y s a t i s f a c t o r i l y a n d t he c o l o n s l o u g h e d in a b o u t h a l f t h e c a s e s . T h i s r e s u l t e d in a m o r t a l i t y r a t e o f s o m e 44 p e r c e n t ( T a b l e I I I ) la r g e l y d u e t o s l o u g h i n g o f t h e c o l o n w h i c h h a d been t r a n s p l a n t e d . H o w e v e r , a m o n g t h o s e w h o s u r v i v e d t h e r e w a s a n a v e r a g e s u r v i v a l o f 15 m o n t h s . I n t h o s e w h o h a d p o s t - o p e r a t i v e r a d i o - t h e r a p y , t h e a v e r a g e s u r v i v a l w a s 11.4 m o n t h s . W i t h t h e t y p e o f r a d i o t h e r a p y w h i c h we h a v e a t o u r d i s p o s a l it is n o t s u r p r i s i n g t h a t a n u m b e r o f p a t i e n t s die s o m e w h a t e a r l i e r , f r o m r a d i a t i o n p n e u m o n i t i s . N o m a t t e r h o w e x p e r t t h e r a d i o t h e r a p y w as , r a d i a t i o n p n e u m o n i t i s m a y wi n. 1 t h i n k th i s will a c c o u n t t h e n f o r t h e s li gh tl y l o w e r a v e r a g e s u r v i v a l o f t h o s e w h o h a v e p o s t - o p e r a t i v e r a d i o t h e r a p y . N e v e r t h e l e s s , t h is s u r v i v a l t i m e is b e t t e r t h a n t h a t for o e s o p h a g o - g a s t r e c t o m y . T h e r e a s o n m a y be t h a t d u r i n g a r e s e c t i o n o f t h e t u m o u r t h e c a n c e r cells a r e d i s t u r b e d by h a n d l i n g t h e t u m o u r , d i s s e m i n a t i n g t h e m t h r o u g h o u t the b o d y . In th i s series, t h e n u m b e r o f s u r v i v o r s w a s o b v i o u s l y c o n s i d e r a b l y s m a l l e r a n d m u s t be r e g a r d e d w i t h a c e r t a i n a m o u n t o f r ese rv e. E ig h t p a t i e n t s d i e d in h o s p i t a l w i t h o u t r a d i o t h e r a p y . W i t h p r e - o p e r a t i v e r a d i o t h e r a p y t h e r e were n o s u r v i v o r s . A m o n g t h e s u r v i v o r s o f t h e b y p a s s o p e r a t i o n , we w e r e s t r u c k by t h e m i n i m a l d i s t u r b a n c e t o th e p a t i e n t s p o s t - o p e r a t i v e l y . W e a r e a l s o i m p r e s s e d by t h e f act th a t t h e r e a r e re la ti v el y l o n g - t e r m s u r v i v o r s . It w a s felt t h e r e fo r e , t h a t t h i s is o b v i o u s l y a n o p e r a t i o n w h i c h h a s s o m e mer it. W e h a v e n o w d ev i s ed a n e w v a r i a t i o n t o t h e o p e r a t i o n . T h e m i d d l e c o l o n is u se d w i t h a b e t t e r b l o o d s u p p l y f r o m the left o r m i d d l e c o l i c vessels. T h e c o l o n is p l a c e d b e h i n d the s t e r n u m , w h i c h is a s h o r t e r d i s t a n c e . T h e n e w i n n o v a t i o n is a v a s c u l a r a n a s t o m o s i s in t h e n e c k to a u g m e n t t h e b l o o d s u p p l y f r o m t h e v a s c u l a r pe d icl es . T h e r i g h t c o l i c a r t e r y a n d veins a r e u se d . T h e t e c h n i q u e o f a n a s t o m o s i s is t h a t o f N a k a y a m a o f J a p a n . T h e i n s t r u m e n t u se d f o r t h e a n a s t o ­ m o s i s b e t w e e n s m a ll vessels is c a l l e d “ N a k a y a m a S m all Vessel A n a s t o m o s i s C l a m p ” . T h i s o p e r a t i o n is a g r ea t a d v a n c e o n t h e p r e v i o u s t e c h n i q u e . T h e r e a r e a t p r e s e n t 10 s u c h p a t i e n t s a n d s u r v i v i n g very sa t i s f a c t o r i l y . I n n o c a s e h a s t h e c o l o n be en lo st. It is felt t h a t s o m e p r o g r e s s in th i s r e sp e c t h a s b e e n m a d e . T h e r e a r e s o m e ca s es w h e r e t h e g r o w t h is t o o h i gh a b o v e t h e a o r t i c a r c h a n d in t h e ne ck t o p e r m i t th i s o p e r a t i o n . O t h e r cases a r e n o t fit f o r m a j o r s u r g e r y . T h e s e p a t i e n t s a r e t r e a t e d by R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) December, 1968 P H Y S I O T H E R A P Y Page 5 r a d i o t h e r a p y . A s I h a v e s a i d , we h a v e a r a t h e r p r i m i t i v e m e a n s o f r a d i o t h e r a p y her e. N e v e r t h e l e s s r a d i o t h e r a p y is e x t r e m e l y effective f o r a li m i te d ti m e . H e r e a g a i n b e c a u s e o f t h e ri sk o f d a m a g e t o l u n g s, th e s e p a t i e n t s , t o o , d e p e n d very m u c h f o r t h e i r e x i s te n c e o n b e i n g a b l e t o b r e a t h e a n d to c o u g h a n d t o e x p e c t o r a t e a d e q u a t e l y , a n d k e e p th ei r lu n g s c l e a r a n d f u n c t i o n i n g . R a d i o t h e r a p y is a m e a n s o f Fig. 8 . Oesophagoscopy. (a) L o o k i n g d o w n t h e o e s o p h a g o s c o p e a t t h e t u m o u r b e f o r e R a d i o t h e r a p y . (,b) T h e s a m e o e s o p h a g u s a f t e r R a d i o t h e r a p y a n d d i l a t a t i o n . Fig. 9. The risks o f endo-oesophageal intubation. (a) P e r f o r a t i o n o f t h e o e s o p h a g u s a t t h e p r o x i m a l e n d o f th e Ce le st i n e T u b e . (b) P e r f o r a t i o n o f t h e s t o m a c h a t t h e d i st al e n d o f t h e t u b e . m a n a g e m e n t w h ic h in it se l f c a n p r o d u c e m o r t a l i t y by v i r tu e o f d a m a g e t o t h e l u n g s. T h e p a t i e n t h a s t o be re la ti ve ly fit to b e a b l e t o s t a n d t hi s f o r m o f t r e a t m e n t w h i c h t a k e s a b o u t five w e e k s t o c o m p l e t e . In se le ct ed cas es as d e s c r i b e d , r a d i o ­ t h e r a p y is t h e t r e a t m e n t o f c h o i c e . T h e t u m o u r is s h r u n k , a n d o e s o p h a g e a l d i l a t a t i o n a f t e r c o m p l e t i o n o f t h e t h e r a p y e n a b l e s t h e p a t i e n t t o t a k e a n o r m a l diet f o r se ver al m o n t h s ( Fi g . 8). T a b l e IV i n d i c a t e s t h e r e s u l t s a c h i e v e d by t hi s f o r m o f t r e a t m e n t . T h e r e s e e m s little p o i n t in s u b j e c t i n g a p a t i e n t t o this p r o t r a c t e d f o r m o f m a n a g e m e n t w h e n t h e e x p e c t a t i o n o f life is n o l o n g e r t h a n a b o u t 8 t o 12 we ek s , i.e. in t h e t e r m i n a l case. T h u s t h e final r e s o r t is p e r m a n e n t e n d o - o e s o p h a g e a l i n t u b a t i o n . R e s u l t s w i t h i n t u b a t i o n h a v e b e e n w o r s t o f all. T h e o r i g in a l o p e r a t i o n t o o k a b o u t 45 m i n u t e s to p e r f o r m , r e q u i r i n g l a p a r a o t o m y a n d g a s t r o t o m y , as well as o e s o ­ p h a g o s c o p y . T h e p a t i e n t is a b l e t o be d i s c h a r g e d 1 t o 2 w e e k s a f t e r o p e r a t i o n . T h e y a r e a b l e t o t o s w a l l o w fluids a n d little else. O f 162 p a t i e n t s ( T a b l e V) h a l f o f t h e m w er e t r e a t e d b e c a u s e th ey w e r e so a d v a n c e d t h a t t hi s w as t h e o n l y f o r m o f m a n a g e m e n t p o ss ib le . T h e o t h e r 80 rec eiv ed this m e t h o d o f m a n a g e m e n t p r e f e r e n t i a l l y f o r v a r i o u s r e a s o n s . T h e r e w er e c i r c u m s t a n c e s f r o m t i m e t o t i m e w h i c h p r e c l u d e d s u r g e r y a n d it w a s n o t b e c a u s e o f t h e fitn es s o f t h e p a t i e n t . T h u s h a l f o f t h e m h a d p r e f e r e n t i a l t r e a t m e n t by i n t u b a t i o n a n d t h e o t h e r w er e t e r m i n a l . I n t e r e s t i n g l y e n o u g h , b o t h o f th e s e h a l v e s s h o w id en t i ca l s u r v i v a l , a f t e r i n t u b a t i o n , o f n o m o r e t h a n t h r e e m o n t h s , w h e t h e r th ey w e r e fit o r t e r ­ m i n a l . T h e r e h a d t o be a r e a s o n f o r this. It b e c a m e e v i d e n t o n s t u d y i n g a u t o p s i e s o f p a t i e n t s w h o di ed a t w id el y v a r y i n g i n t e r v a l s a f t e r i n t u b a t i o n . A s m a n y as 56 d i e d in h o s p i t a l ; t h e o p e r a t i v e m o r t a l i t y w as 34 p e r c e n t . It w o u l d be u n f a i r t o c r it ic is e t h e p r o c e d u r e b e c a u s e o f this o p e r a t i v e m o r t a l i t y , a s h a l f o f t h e p a t i e n t s w e r e t e r m i n a l . T h i s w o u l d i n c r e a s e t he Fig. 10. The new Livingstone Hospital tube. (a) A n t e r i o r view. (b) L a t e r a l view. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 6 P H Y S I O T H E R A P Y December, 1968 operative m ortality, but the short survival requires explana­ tion. In 27 autopsies on patients who have died after the tube had been inserted, 22 o f them died as result o f the tube, which was actually the instrument o f death. In o n ly five was the cause o f death due to m etastases or respiratory com plica­ tions. The tube causes perforation o f the oesoph agus or stom ach either end (Fig. 9). T his tube, designed by Celestin, is m ade o f fairly rigid plastic material. It extends from just ab ove the grow th, dow n into the stom ach, requiring an abdom inal operation. A new tube has been devised at Livingstone H osp ital, which is inserted by oesoph agoscopy alone. The design is such that the risk o f perforation o f oesoph agus is reduced considerably, and perforation o f the stom ach is obviated altogether (Fig. 10). R esults with tube have so far, been very satisfactory. Such is the som ew hat dismal report o n the m anagem ent o f oesophageal carcinom a, which I have described as an incurable cancer, in the pop ulation served by L ivingstone H ospital. N otw ith stand in g this, we m ay derive considerable encouragem ent from a com parative analysis o f results if all cases are divided in to an early and a late h a lf (Table VI). The early series consists o f 273 cases treated from 1964-66, and the latter series, 250 cases treated in 1966-67. In the latter hospital m ortality (27.2 per cent) is appreciably lower than in the former (39.1 per cent). T his is accounted for by a number o f factors. 1. Few er refuse treatment (Table VI). 2. The patients are presenting som ew hat earlier (albeit by no m eans early enough), as evidenced by the smaller numbers w ho die before treatment is even started. This displays an increasing trust in hospital treatment and em phasises the value o f the diagnostic clinic in Butterworth. 3. The operative m ortality from oesophagogastrectom y is m ore than halved, from 23.5 per cent in the early period, to less than 11 per cent. T able VI indicates an operative m ortality o f 16 per cent in those w ho did n o t have pre­ operative radiotherapy in 1966-67. D u ring the period 1967- 68 , subsequent to cessation o f pre-operative radiotherapy, the operative m ortality is less than 11 per cent in 48 opera­ tions. This considerable reduction has n o t been achieved so m uch by im proved operative technique. O ne is probably as clum sy now as ever, although operating time has been reduced by an hour or more. T he principal and m ost im portant factor has been the increasing awareness o f the necessity and value o f pre- and im m ediate post-operative physiotherapy o f an intensive quality. Ward staff m aintains a vigorou s regim e in this respect, after instruction by our physiotherapists, M isses H ob son , B lenkinsop and Javal. The alteration in m ortality rates with the individual treatm ents, has n o t altered trem endously. B ut if we take a com bination o f patients treated by radiotherapy and intubation together in the 1st and 2nd periods, the figures are alm ost exactly inversely proportional. In the early period the ratio was 30 to 135, while in the later period the ratio was 137 to 27, m aking totals o f 165 with 51 deaths, and 164 with 33 detahs respectively. This reduction in m ortality rate o f com bined m eth ods o f therapy is considerable. Thus where radiotherapy is the preferential therapy (o f these tw o m ethods), the m ortality is considerably lower. Y et in the individual m eth ods o f treatment there is n o t a very signi­ ficant low ering o f m ortality. W ith better m eans o f therapy we m ay im prove on this even further. A new trial has been com m enced where we are com bining radiotherapy with chem otherapy which is now becom ing a popular m eans o f com bating cancer. T he drug we use is M ethotrexate. S o far we have had encouraging results from radio-sensitization with chem otherapy and then subjecting the tum our to radiotherapy. W ith this we h op e that our m ortality will be low er and m ore im portant— this therapy should be m ore effective. The Provincial A dm inistration has encouraged us in this project and has given us an ade­ quate am ount o f equipm ent, b o th here in L ivingstone H ospital and at the little hospital in the Transkei, at Butter- worth. T hus we can m ake a m ore accurate early diagnosis w hich m ay ultim ately unm ask this clandestine cancer. Our thanks go to the H ospital A dm inistration authorities in C ape T ow n for this recognition and assistance. TABLE I Summary o f Results over the Total Four-year Period. C A R C IN O M A O F O E S O P H A G U S 1964-1967 L iv ing sto ne H o s p it a l, P o r t E liz a b e t h D ied in H ospital L ongest Survivor (M onths) Average Survival (M onths) A fter or during Treatment Before Specific Treatment D ie d at H om e Still A live L ost to F ollow -u p Total 117 (22.4% ) 54 (10.3% ) (45.5% ) 36 8.4 28 86 (14.6% ) 523 171 (32.7% ) R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) TA BLE II Summary o f Results from Oesophagogastrectomy 1964-1967_______________________________ December, 1968 P H Y S I O T H E R A P Y Page 7 O E SO P H A G O -G A ST R E C T O M Y D ie d in H ospital Longest Survivor (M onths) Average Survival (M onths) Still A live Lost to F ollow -u p Total A lon e 24 8.6 6 13 51 W ith P ost-operative R adiotherapy Radiotherapy only ► 2 0 .2 % 36 9.4 5 4 38 W ith Pre-operative R adiotherapy 8 44.4% 12 6.5 4 3 18 T otal 26 24.3% 36 8.2 15 20 107 TA BLE III Summary o f Results from O esophagocolic Bypass 1964-1967 O E SO PH A G O -C O L IC B Y -P A S S D ied in H ospital L ongest Survivor (M onths) A verage Survival (M onths) Still A live L ost to F ollow -u p T otal A lon e 8 24 15 0 1 11 W ith Post-operative R adiotherapy 0 24 11.4 2 1 8 W ith Pre-operative Radiotherapy 2 — — — — 2 Total 10 24 13.2 2 2 21 TABLE IV Summary o f Results from Radiotherapy 1964-1967, Excluding Pre- and Post-operative Radiotherapy R A D IO T H E R A P Y D ie d in H ospital Longest Survivor (M onths) A verage Survival (M onths) Still A live L ost to F ollow -u p Total A lon e 16 18 6.9 10 23 129 W ith Tube 4 12 3.8 0 3 16 W ith G astrostom y 5 12 5.5 1 4 22 Total 25 18 5.4 11 30 167 TA BLE V Summary o f Results from Intubation 1964-1967 IN T U B A T IO N D ie d in H ospital Longest Survivor (M onths) Average Survival (M onths) Still A live L ost to F ollow -u p Total Overall 56 30 3 0 34 262 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 8 P H Y S I O T H E R A P Y December. 1968 TABLE VI Results in Comparison between Two Consecutive Periods 1964-1966 and 1966-1967 Year R efused Treatment D ied B efore Treatment O esophago- Gastrec- tom y O esophago- C olic By-pass R a d io ­ therapy Intubation Total 1964 18 37 Total 51 13 30 135 273 to 1966 6 .6 % 13.9% D ied in H ospital 12 23.5% 6 46.6% 5 16.6% 46 34.1% 106 39.1% 1966 10 17 Total 56 *38 t l 8 8 137 27 250 to 1967 4% 6.8 % D ied in H ospital *6 14 f 8 *16% 25% t4 4 % 4 50% 20 14.6% 13 48.1% 68 27.2% ♦W ithout Pre-operative Radiotherapy. fW ith Pre-operative R adiotherapy. Paper delivered at the Post-R egistration Course at S.A .S.P . N ation al Council M eeting in Port Elizabeth, M ay, 1968. DERANGEMENTS OF THE KNEE T H EIR R E C O G N IT IO N A N D T R E A T M E N T M r . J. D . O S M O N D , f .r .c .s ., H ead o f D epartm ent o f O rthopaedics, Livingstone H ospital, Port Elizabeth. The P hysiotherapist has alw ays fulfilled an integral and important role in O rthopaedic Surgery. One can state categorically that m o d e m orthopaedics is ju st n o t feasible w ithout the assistance o f the “ P h ysio” . We “ O rth opods” are very jealou s and proud o f this special relationship. I have chosen to speak abou t the knee-joint as this is a surgical field where our com bined talents are com m only required. A lso , the knee-joint ranks second only to its upstairs neighbour, the hip, in im portance. Derangem ent, in its orthopaedic context, m eans a m echanical m alfunction. The knee-joint is a reasonably uncom plicated hinge-m echanism but is particularly vulner­ able to derangem ent o n accou nt o f a num ber o f fa c to r s: 1. T H E A N A T O M Y is such that there is n o bony stability such as we encounter in the other great weight-bearing jo in ts o f the low er limb, i.e. The ball-socket o f the hip, the ankle-m ortice, the virtually unshiftable sacro-iliac jo in t with its great supporting interosseous ligaments. This means that the knee depends for stability o n its ligam ents and m uscular support, the latter principally provided by the quadriceps. T he quadriceps are all-im portant and m aintenance or restoration o f quadriceps bulk and pow er is w ithout doubt the m ost im portant single ortho­ paedic fun ction o f the “ P h ysio” . “ Quads. E x .” is the cardinal way back to health o f the deranged knee and I cannot over-em phasize its im portance. It is furthermore a paradox o f locom otor fun ction that these great m uscles are invariably inhibited and wasted in any derangem ent, w hile the hamstrings are n o t sim ilarly affected. 2. SU SC E PT IB IL IT Y TO T R A U M A T IC D E R A N G E ­ M E N T . In this era o f high-speed travel and organised vigorous sporting activity, it is n o t surprising that the knee com m on ly bears the brunt o f a traumatic m isfortune. The classic rugby tackle is directed against the outerside o f the knee, and before this winter is over, a few m ore crippled players w ill be receiving your and our attention. A rticular fracture o f the knee is outsid e the scope o f this address and traum atic injuries will be confined to soft-tissue structures. 3. M IN O R C O N G E N IT A L A N O M A L IE S . The knee-1 jo in t is quite com m on ly the seat o f m inor congential ano­ malies such as knock-knee or patellar instability. These m ay give rise to quite severe disability. Furtherm ore, aggravating deform ities or predisposing weakness m ay result from m alnutritional states, such as rickets. D erangem ents o f the knee are usually classified as internal or e xtern al but for the purpose o f brevity, and since this classification d oes not really help on e appreciate the problem any better, I am going to describe derangem ents in their order o f clinical frequency. A . L IG A M E N T O U S IN JU R IE S . These m ay vary from m inor sprains to com plete ligam ent rupture or avulsion. Since the disability caused by, and treatment required for rupture or avulsion is the sam e, I will n o t separate these two entities and refer to them under the com m on heading ‘R u pture’. M inor Sprains are benign and w ill recover whatever treatm ent is, or is n o t, instituted. T hey m ay be associated w ith considerable early pain and thus be over-diagnosed and, consequently, overtreated. Certain sim ple criteria should help on e to ascertain whether a sprain is a minor one: R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )