Certificate from the DEAN
This is to certify that this dissertation entitled “CLINICAL STUDY ON
CARCINOMA ESOPHAGUS IN GOVERNMENT RAJAJI HOSPITAL,
MADURAI” is the bonafide work of Dr.M.Udayakumar., in partial fulfillment of
university regulations of the Tamil Nadu Dr. M.G.R. Medical University, Chennai, for M.S General Suregry Branch I examination to be held in April 2015.
Captain Dr.B. SANTHAKUMAR , M.Sc(F.Sc) , M.D(F.M)., PGDMLE., Dip.N.B (F.M) .,
THE DEAN
Madurai Medical College and Government Rajaji Hospital, Madurai.
INCIDENCE, PATHOLOGICAL PATTERN AND MANAGEMENT OF
II
Certificate from the HOD
This is to certify that this dissertation entitled “CLINICAL STUDY ON INCIDENCE, PATHOLOGICAL PATTERN AND MANAGEMENT OF CARCINOMA ESOPHAGUS IN GOVERNMENT RAJAJI HOSPITAL ,
MADURAI” is the bonafide work of Dr. M . UDAYAKUMAR ., in partial fulfillment
of university regulations of the Tamil Nadu Dr. M.G.R. Medical University, Chennai, for M.S General Surgery Branch I examination to be held in April 2015.
Dr.A.Sankaramahalingam, M.S.
Professor and HOD,
Department Of General Surgery, Government Rajaji Hospital, Madurai Medical College, Madurai.
III
Certificate from the GUIDE
This is to certify that this dissertation entitled “CLINICAL STUDY ON INCIDENCE, PATHOLOGICAL PATTERN AND MANAGEMENT OF CARCINOMA ESOPHAGUS IN GOVERNMENT RAJAJI HOSPITAL, MADURAI” is the bonafide work of Dr. M.UDAYAKUMAR ., in partial fulfillment of university regulations of the Tamil Nadu Dr. M.G.R. Medical University, Chennai,
for M.S General Surgery Branch I examination to be held in April 2015
Dr.N.Vijayan, M.S Professor of Surgery ,
Department Of General Surgery, Government Rajaji Hospital, Madurai Medical College, Madurai.
IV
DECLARATION
I , DR. M.UDAYAKUMAR , solemnly declare that this dissertation
“CLINICAL STUDY ON INCIDENCE, PATHOLOGICAL PATTERN AND MANAGEMENT OF CARCINOMA ESOPHAGUS IN GOVERNMENT RAJAJI HOSPITAL, MADURAI” is a bonafide record of work done by me at the Department Of General Surgery, Government Rajaji Hospital , Madurai , under the guidance of Dr.N.VIJAYAN, M.S, Professor , Department of General Surgery, Madurai Medical college , Madurai.
This dissertation is submitted to The Tamil Nadu Dr. M.G.R Medical University, Chennai in partial fulfillment of the rules and regulations for the award of M.S Degree General Surgery Branch- I; examination to be held in April 2015.
Place: Madurai Date:
Dr.MUDAYAKUMAR,
V
ACKNOWLEDGEMENT
I would like to thank Captain Dr.B. SANTHAKUMAR , M.Sc(F.Sc) , M.D (F.M)., PGDMLE., Dip.N.B (F.M) ., Dean Madurai Medical College and Government Rajaji Hospital, for permitting me to utilize the facilities of Madurai Medical College and Government Rajaji Hospital facilities for this dissertation.
I wish to express my respect and sincere gratitude to my beloved teacher and Head of The Department, Prof. Dr.A.SANKARAMAHALINGAM, M.S., Professor of Surgery for his valuable guidance and encouragement during the study and also throughout my course period.
I would like to express my deep sense of gratitude, respect and thanks to my beloved Unit Chief and Professor Of Surgery, Prof. Dr.N.VIJAYAN, M.S., for his valuable suggestions , guidance and support throughout the study and also throughout my course period .
I am greatly indebted to my beloved Professors , Dr. NASHEER AHMED SYED , M.S., Dr. SELVA CHIDHAMBARAM, M.S., Dr. MARUTHUPANDIAN, M.S., Dr. LAKSHMI , M.S., Dr. SYED IBRAHIM , M.S., and
Dr. DHAMODHARAN ,M.S., for their valuable suggestions throughout the course of the study.
VI
I am extremely thankful to Assistant Professor of Surgery of my Unit,
Dr.K.SARAVANAN, M.S., Dr.M.MANIKANDAN, M.S.,
Dr.P.MUNIASAMY, M.S., for their valid comments and suggestions.
I sincerely thank the Professor of Surgical Gastroenterology, Prof.Dr.
S.PADMANABHAN, M.S. M.Ch (SGE) & the Professor of Surgical Oncology, Prof.Dr. S.S.SUNDARAM, M.S. M.Ch (Surgical Oncology) for their guidance and suggestions in my dissertation work.
I sincerely thank all the staffs of Department Of General Surgery and Department Of Surgical Gastroenterology & Surgical Oncology for their timely help rendered to me, whenever needed.
I extend my thanks to all my friends, batch mates, any senior and junior colleagues who have stood by me and supported me throughout my study and course period.
Finally, I thank all my patients, who form the backbone of my study, for their patience and co-operation .I pray god for their well-being and their speedy recovery.
VII
VIII
LILISSTT OOFF AABBBBRREEVVIIAATTIIOONSNS
A A → → AvAveerraaggee
AC → Adenocaarciinnoomma AG → Agricuullturiisst B B → → BuBussiinneessss ppeerrssoonn B. Pneu → Bronchhooppnneeumoniaa CaCa → → CaCarrcciinnoommaa
CE → Carrccinnoommaa Esophagus D → Depennddeent
DODOAA → → DaDattee ooff AAddmmiissssiioonn
F → Femmaale
G G → → GoGooodd HW → Houseewiife I
IPP NNOO.. → → InIn ppaattiieenntt NNuummbbeerr M M → → MaMallee
RLNN → Reccurrennt LLaryngeaal Nerve SCSCCC → → SqSquuaammoouuss CCeellll CCaarrcciinnoommaa
IX
ABABSSTTRRAACCTT
NENEEEDD FFOORR SSTTUUDDYY
Benniign ttumoorrss ooff tthe esoopphhaagus are a rare anndd arree ususuallly more bothheer- ssomee than t harrmmful. TThe mmoosstt coommmmon tyyppee of bbeenign ttumor iiss aa leeiomyyoomma wwhicchh occcuurrss iin peoopplle bebettwweeeenn 3030 anandd 6060 yeyeaarrss ooff aaggee.. OtOthheerr tutummoorrss ccoonnssiisstt ooff fifibbrroovvaassccuullaarr popollyyppss anandd Schwannommaas.. Benniign tumors t ofof essophagguuss is vevery rarare compprriissiing ofof 0.5 tto 00..88%% ofof esesoopphhaaggeeaall ttuummoorrss..
Carrccinnoommaa ofof essophagguuss is the t ninthh momosst coommmon cannccerr inn the wworldd.. NuNummeerroouuss ssttuuddiieess hhaavvee ddeemmoonnssttrraatteedd ththaatt iinn ddeevveellooppiinngg ccoouunnttrriieess cciiggaarreettttee ssmmookkiinngg anandd allcoohhooll cconsuummptioonn are the t mmoosstt imppoorrttant prpreedisposiing faccttor for essophagguuss c
caarrcciinnoommaa..
Barrrreett’’ss eesoopphhaagus iss aa conseqquueenncce ooff chroonniicc ggaassttrroo essophaggeeaal rreefleexx dissorderr whwhiicchh isis ththee mmoosstt imimppoorrttaanntt ririsskk fafaccttoorr foforr adadeennooccaarrcciinnoommaa ooff eessoopphhaagguuss.. SeSevveerraall essophaggeeal mmotiillittyy disorders havvee beenn iimpliicattedd inin the ddeevellooppmment of esophageaal cacarrcciinnoommaa..
Carrccinnooggeenniic eefffeecttss ooff tobaccco aand allccohol iis far mmoorree pronounceed for ssquamoouuss cecellll ccaarrcciinnoommaa tthhaann ffoorr aaddeennooccaarrcciinnoommaa..
Reccent epide deemmiolooggiicaall sttudiees hahave found thhaat oobbeessiitty (meeaasuurred ass body maasss ininddeexx)) iiss ananootthheerr ststrroonngg rriisskk fafaccttoorr foforr esesoopphhaaggeeaall cacarrcciinnoommaa ssqquuaammoouuss cecellll cacarrcciinnoommaa seenn iin asssoocciattion withh ssmookkiing and alcohol.l .
XI RERESSUULLTTSS
A toottall of 3300 ppaatiieentss wwerree operraattedd wwitth aaggee ggrroup ((4400--8877yyrrss)) wwiitth 2200 mmalees anndd 1010 ffeemmaalleess (r(raattiioo 2:2:11)) sqsquuaammoouuss cecellll caca (7(700%%)),, AdAdeennooccaarrcciinnoommaa ((3300%%)) cacarrcciinnoommaa ofof Loowwerr tthhiird eesophagus is i moorree commc moonn.. ((>>70%) of ppaatiieentss beloonnggeed to t bbllood group A A (4(466..66%%)) oorr OO ((2266..66%%)).. ToTobbaaccccoo SmSmookkiinngg//cchheewwiinngg,, alalccoohhooll coconnssuummppttiioonn,, chchrroonniicc i
irrrriittaattiioonn aanndd pprree--eexxiissttiinngg eessoopphhaaggeeaall ccoonnddiittiioonnss aarree ssttrroonngg rriisskk ffaaccttoorrss..
COCONNCCLLUUSSIIOONN
Toobbaaccoo,, ssmookkiing/chheewiing and allccohol coconnssuummppttioonn anandd prpreeexxiissttiing esophageaal coconnddiittiioonnss aarree ssttrroonngg rriisskk ffaaccttoorrss.. DDiisseeaassee sshhoowwss pprreeddoommiinnaannccee ttoo mmaallee,, mmoorree ccoommmmoonn iinn 5
5thh && 66tth ddeeccaaddee ooff lliiffee.. SSqquuaammoouuss cceellll ccaarrcciinnoommaa iiss mmoorree ccoommmmoonn tthhaann aaddeennooccaarrcciinnoommaa Differreent surgics cal aapproachh has no effffeect oonn duratiion of hospitaal stasay, mortaaliitty or susurrvviivvaall..
KeKeyywwoorrddss
Carrccinnoommaa esophagus; Adenocaarcinnoommaa; SSquammoous ccelll carrccinomaa
XII
TATABBLLEE OOFF COCONNTTEENNTTSS
S Sl..
No. N Topic Paaggee No.o.
11.. INTRODUUCTIIOON 1
22.. AIAIMM OOFF TTHHEE SSTTUUDDYY 3 3
33.. HISTTORRIICCAAL AASPEECTS 4
44.. REVVIEWW OFF LITITERATURE 7
5
5.. SUSURRGGIICCAALL AANNAATTOOMMYY 1414 66.. GEGEOOGGRRAAPPHHIICC DDIISSTTRRIIBBUUTTIIOONN 2222 7
7.. ETTIOPPATHOGGENNESSIS 24
88.. TRTRAANNSSHHIIAATTAALL EESSOOPPHHAAGGEECCTTOOMMYY 2828 9
9.. MEMETTHHOODDOOLLOOGGYY 4343
1010.. RESSULTSS 50
1111.. DISCCUUSSIIOON 77
1212.. COCONNCCLLUUSSIIOONN 8989
1313.. SUMMMARRYY 92
1
144.. BIBLIIOOGRAPPHY 94
ANANNNEEXXUURREESS
• • PPrrooffoorrmmaa 101077
•
• MMaastter Charrtt 116
1515..
• KKeeyy ttoo tthhee MMaasstteerr CChhaarrtt 118
XIII
LILISSTT OOFF TTAABBLLEESS
TaTabbllee
NoNo.. ToToppiicc PaPaggee NNooss.. 11.. Age disstrriibutioonn ooff ppaatieents sttudiedd 5500 2
2.. Genderr ddiisttributiion of patiientss studied e 5522 33.. Occuuppaatioonn ooff ppaatieents sttudiedd 5533 44.. DuDurraattiioonn ooff ddiisseeaassee iinn mmoonntthhss 5544 55.. ClCliinniiccaall ffeeaattuurreess 5555
66.. Habitts 5566
7
7.. Comoorrbbiid condittions 5577
88.. H/o resspirraatory ailmei ents preoperraativveely 5588
99.. AnAneemmiiaa 5599
1010.. HeHemmoogglloobbiinn ((%%)) 6600
1111.. AlAlbbuummiinn 6611
1
122.. Bloooodd ggrroouupp 6622
1313.. Histopatthologiccal EExamiinatiion 6633
XIV
1414.. DuDurraattiioonn ooff hhoossppiittaall ssttaayy ((ddaayyss)) 6644
1515.. Surgicaal proceedure 6655
1
166.. Comppllicaatioonnss durinngg ssurgerryy 6666 1
177.. PoPossttooppeerraattiivvee ccoommpplliiccaattiioonnss 6677 1818.. PoPossttooppeerraattiivvee RRTT aanndd CCTT 6688
1919.. OuOuttccoommee 6699
2020.. Correllatiion ofof clclinniiccall vavarriabbllees witwth ououttcomee (P(Post--oopp
coommpplliccatiions//delaayed coommpplliccatiionss//Moorrttaliity) 7700 2
211.. Taable sshowing peak a age iinciddeence bbyy vvaarrious authhoorrss 8800 2
222.. MeMeaann AAggee iinn YYeeaarrss 8800 2323.. MaMallee ttoo FFeemmaallee rraattiioo 8811 2424.. Present SStuuddyy--AAngiooggrraaphic LLevell of Diiseease 8844
2525.. Bloooodd ggrroouupp 8844
2
266.. Comppaarison sttudiess hisstooppaatholooggiicall behavviiour ooff ttumoorr 8855 2
277.. CoCommppaarriissoonn ssttuuddiieess bblloooodd lloossss 8866 2828.. CoCommppaarraattiivvee ssttuuddiieess ooff dduurraattiioonn ooff hhoossppiittaall ssttaayy 8877
XV
LLIISTST OFOF FFIIGGUURREESS
FiFigguurree
NoNo.. ToToppiicc PPaaggee
NNooss.. 11.. Surgicaal annaatomyy ooff eesoopphhaagus 1515 2
2.. Arterriial bbllood suupppplly of esophagus 1717 33.. Venous drainnaage of essophagguuss 1818 44.. LyLymmpphhaattiicc ddrraaiinnaaggee ooff eessoopphhaagguuss 1919 55.. NeNerrvvee SSuuppppllyy ooff EEssoopphhaagguuss 2121 66.. Mobiliisaatioonn ooff tthe stomaach 4141 7
7.. Preparraatioonn ooff ggaasttric cconduit 4141 8
8.. Mobiliisaatioonn iin the nneeck 4242 99.. AnAnaassttoommoossiiss iinn tthhee nneecckk 4242 1010.. BaBarr ggrraapphh sshhoowwiinngg aaggee ddiissttrriibbuuttiioonn 5151 1111.. Pie ggrraaph shhoowwinngg ggeender disstrriibutioonn 5252 1
122.. Barr ggrraaph shhoowwinngg oocccupattion 5353
XVI 1
133.. Barr ggrraaph shhoowwinngg dduurraatioonn ooff ddiiseeasee inn mmoonntths 5454 1414.. Barr ggrraaph shhoowwinngg mmode of pressennttatiioonn 5555 1515.. BaBarr ggrraapphh sshhoowwiinngg hhaabbiittss 5656 1616.. PiPiee aanndd BBaarr ggrraapphhss sshhoowwiinngg ccoommoorrbbiidd ccoonnddiittiioonnss 5757 1
177.. PiPiee ggrraapphh sshhoowwiinngg hhiissttoorryy ooff rreessppiirraattoorryy aaiillmmeennttss 5858 1
188.. Pie ggrraaph shhoowwinngg aanemiia 5959 1919.. Barr ggrraaph shhoowwinngg hheemogloobbiin (%) 6060 2020.. BaBarr ggrraapphh sshhoowwiinngg sseerruumm aallbbuummiinn ((%%)) 6161 2121.. BaBarr ggrraapphh sshhoowwiinngg bblloooodd ggrroouupp aammoonngg ppaattiieennttss ssttuuddiieedd 6262 2
222.. PiPiee ggrraapphh sshhoowwiinngg hhiissttooppaatthhoollooggiiccaall eexxaammiinnaattiioonn ((HHPPEE)) 6363 2
233.. Barr ggrraaph shhoowwinngg dduurraatioonn ooff hhoosspittal sstaay (days) 6464 2424.. Pie ggrraaph shhoowwinngg ccompliicattions during surgery 6666 2525.. PiPiee ggrraapphh sshhoowwiinngg ppoossttooppeerraattiivvee ccoommpplliiccaattiioonnss 6767 2626.. PiPiee ggrraapphhss sshhoowwiinngg ppoossttooppeerraattiivvee RRTT//CCTT 6868
XVII 2
277.. Pie ggrraaph shhoowwinngg oouuttcomee 6969 2828.. Ennddoosscooppiic piccture sshowing superficciall malliignanntt eesophageaall caancerr 7171 2929.. EnEnddoossccooppiicc ppiiccttuurree sshhoowwiinngg pprroolliiffeerraattiivvee ggrroowwtthh 7171 3030.. EnEnddoossccooppiicc ppiiccttuurree sshhoowwiinngg mmaalliiggnnaanntt ssttrriiccttuurree ooff eessoopphhaagguuss 7272 3
311.. EnEnddoossccooppiicc ppiiccttuurree sshhoowwiinngg mmaalliiggnnaanntt cciirrccuummffeerreennttiiaall uullcceerr 7272 3
322.. CT ffiilm sshowing Ca mmiddlee thirrdd eesoopphhaagus 7373 3333.. CT ffiilm sshowing Ca lloweer thirrdd eesoopphhaagus 7373 3434.. EsEsoopphhooggoo--ggaassttrreeccttoommyy ssppeecciimmeenn 7474 3535.. MaMalliiggnnaanntt ssttrriiccttuurree ccaauussiinngg 8800%% nnaarrrroowwiinngg ooff lluummeenn 7474 3
366.. MaMalliiggnnaanntt ttuummoouurr ooff mmiiddddllee--tthhiirrdd eessoopphhaagguuss 7575 3
377.. Maliignant ttumour of loowwerr--tthird of essophagguuss 7575 3838.. Histopatthologiccal ssliide showiing adennooccaarciinnoomma 7676 3939.. HiHissttooppaatthhoollooggiiccaall sslliiddee sshhoowwiinngg ssqquuaammoouuss cceellll ccaarrcciinnoommaa 7676
1
INTRODUCTION
Tumours of the esophagus are among the most challenging problems confronting the surgeons.1
Benign tumors of the esophagus are rare and are usually more bothersome than harmful comprising of (0.5-0.8%) all esophageal tumors.2
Esophageal cancer represents one of the most lethal malignancies affecting the mankind.3 It is the 9th most common carcinoma of all carcinomas.4 Adenocarcinoma of the esophagus is increasing in incidence at a rate exceeding that of any other neoplasm.5 Once the overt symptoms appears the average survival rate without treatment is 9 months.6
Most of the patients in our setup presents in the late stages. Considering the rate of blockage of stents and cost of procedure more emphasis in laid on the surgical procedure which gives long term relief compared to other procedures.
After several studies controversy still exist regarding the operative management of carcinoma esophagus even in Indian setup.
Surgical therapy remains the mainstay therapy for patients with respectable carcinoma both therapeutically as well as palliatively.7
2
Palliation is the primary goal for patient with locally advanced cancers and those with metastasis. Primary goal of palliation is restoration of swallowing, relief of plain and local control of the disease.8 To achieve this surgical resection gives best results in all forms of esophageal cancers.2
Transhiatal esophagectomy can be performed with minimal morbidity and is the desired operation of choice5 and it is better tolerated physiologically.4 It also confers the advantage of a radical approach and incorporates near total esophagectomy and cervical anastomosis.9,10
There are many studies reported in the literature which have student the transhiatal esophagectomy and its complications. However, there is necessity to evaluate he complications more precisely and group them in form of operative postoperative complications. Also, comparing such type with mode of presentation and other pre existing systemic illnesses. There is a need for a new study to evaluate the complication with respect to their preoperative factors.
4
HISTORICAL ASPECTS
2500 BC: “Smith Surgical Papyrus” described repair of the “gullet” after perforation (no indication malignancy was involved)
AD 0-1: Chinese described esophageal dysphagia from carcinoma.
Circa 2nd Century: Galen described fleshy growths causing obstruction of the gullet.
1849: Long described first use of sulfur either as an anesthetic.
1868: Kussmaul is the first to pass a lighted tube through the entire esophagus into the stomach.11
1869: Trendelenburg employs the endotracheal route for administration of anesthesia.12
1871: Billroth successfully resected and reanastomosed the cervical esophagus in dogs.13
1897: Czerny is the first to successfully resected the cervical esophagus for carcinoma in humans.14,15
1989: Roentgen published his early investigations on the use of “x-rays”.
1898: Rehn attempted resections of an esophageal carcinoma via right posterior mediastinotomy in two patients, unsuccessfully.
5
1901: Dobromysslow successfully performed the first intrathoracic resection and reanastomosis of the esophagus in dogs.
1905: Beck described formations of the gastric tube from the greater curvature of the stomach, based on the gastroepiploic artery.
1907: Wendell described transpleural resection of an esophageal carcinoma of the lower esophagus with lateral esophagogastrostomy in a lumen (patient dies the following day).
1908: Volecker successfully resected a carcinoma of the gastresophageal junction with primary esophagogastrostomy via laparotomy.
1913: Zaaijer successfully resected a carcinoma of the cardia via an abdominothoracic approach.16
1913: Denk described the “blunt” or “blind” esophagectomy.17
1913: Turner described the thoracic abdominal approach for blindly mobilizing the resecting the thoracic esophagus.18
1933: Oshawa resected the thoracic esophagus for carcinoma with immediate esophagogastrotomy (8 of 18 patients survive).19
1938: Admas is the first surgeon in the United States to perform transthoracic esophageal resection with immediate esophagogastrotomy.4
6
1946: Ivor Lewis introduced esophagectomy and esophagogastrostomy through a right thoracotomy.20
1947: Sweet completed 212 resections for esophageal carcinoma (17% operative mortality and 8%, 5- year survival).
1963: Logan described 853 resections for esophageal carcinoma (29% operative mortality).
1978: Orringer and Sloan revived the technical of Gray Turner’s
“esophagectomy without thoractomy”.21,22
1984: Leichman et al at Wayne State University combine 3,000 cGy with two cycles of 5-FU and cisplatin preoperatively in 21 patients with squamous cell carcinoma of the esophagus (37% pathologic complete response; operative mortality 27%).23
1997: Multiple phase III randomized trials fail to show significant survival benefit for neo adjuvant multimodality therapy.
7
REVIEW OF LITERATURE
Esophageal cancer represents the third most common gastrointestinal malignancy and ranks among the ten most common cancers worldwide.24 U.S. mortality data from 1990-1994 have revealed a steady increase in age adjusted mortality in males as well as females subjects, due to this malignancy.25
The combined incidence of adenocarcinoma of the esophagus and cardia in currently estimated at 5.8 per 1,00,000 ranking this tumor among top 15 cancer of white men in United States.26
In India squamous cell carcinoma is more common and accounts for nearly 75%
of cases. The incidence of esophageal cancer in women is much lower.27,28
Through cultural as well as dietary practices contribute to esophageal cancers, tobacco and ethanol are believed to be primary risk factors.25,29,30,31
A five to ten fold increase in esophagus squamous cell cancers has been noted smokers relative to non-smokers and risk of esophageal carcinoma correlates with extent of tobacco exposure.29,32,33
A multicentric study by Gammon et al as well as additional clinical studies have indicated that the risk of esophageal cancer is approximately two fold higher in smokers compared with non-smokers.25,34
8
Alcohol abuse has been associated with increased risk of esophageal cancers and the risk increases with the amount of alcohol consumed.35,36
Vaughan TL and Brown LM demonstrated in two different studies that obesity may be related to risk of esophageal cancer, particularly adenocarcinoma.37,38
Esophageal squamous cell carcinomas have been associated with nutritional deficiencies; a low intake of fruits and vegetable may influence the esophageal cancer risk two fold.25,39,40 Deficiencies in carotene, vit, E, and selenium may also increase the risk of squamous cell carcinoma in underdeveloped areas.
Dietary practices including drinking hot beverages or ingestion of fermented vegetables may contribute to increased cancer risk.41,42
Esophageal cancer should be suspected in any patient complaining of dysplasia and weight loss. A through history should be ascertained focusing on preexisting conditions as well as tobacco and ethanol abuse which are known to be associated with cancer risk.
The most common symptom of esophageal carcinoma at the time of presentation is dysphagia3 palliation is the primary goal for patient with advanced local cancers and metastasis. Primary goal of palliation is restoration of swallowing and relief of plain.8
9
Dysphagia is the most common symptom at the time of presentation.43 This unfortunately is a late sign because the esophageal wall is easily distensible due to lack of serosa.44 Dysphagia leads to various problems like weight loss, malnutrition and aspiration pneumonia.45 Anorexia malnutrition, loss of weight cardiovascular and pulmonary problems will have direct impact on morbidity and long term survival.46,47
Age is also an important prognostic factor as patients over age 70 undergoing esophagectomy have a postoperative morality of 13%.48
Surgery represents the best chance for cure and best palliation for dysphagia and local control of the disease.8 Surgical resection gives the best results for all forms of esophageal cancers.4
The incidence of esophageal stricture is very less in surgery when compared to radiotherapy.7,49
Most surgeons favour transhiatal resection of esophagus which involves posterior mediastinal blunt dissection without throracotomy.7,50
Transhiatal esophagectomy can be performed with minimal morbidity and is the desired operation of choice and its is better tolerated physiologically.4 It also confers the advantage of radical approach under direction vision and incorporate near total esophagectomy and cervical anastomosis.9,10
10
The main goals of this procedure are to resolve dysphagia, to achieve a operative mortality of less than 10%, to prevent the complications and morbidity (e.g. Infection, Stricture, reflux and aspiration).8,50
This procedure is preferred in patients of respiratory functions impairment who are not fit for thoracotomy.7 Regardless of level of tumor the maximum vertical surgical margin possible is obtained minimizing suture line tumor recurrence. Postoperative deaths from mediastinitis and sepsis resulting from anastomotic disruption is vertically eliminated also clinically significant gastresophageal reflux seldom occur.9
A study by Randini-Martini et al showed no apparent difference in postoperative morbidity in Ivor-Lewis when compared with transhiatal esophagectomy and Ivor-Lewis procedure had more mortality rate.51
Morbidity in form of blood loss, operating time and fewer days in ICU is very less despite being performed in older patients.52
Hand sewn anastomosis (oesophago-gastric) are better than the stapled ones in esophagectomy as demonstrated by Laterza et al.53
The choice of the operation for carcinoma esophagus depends upon many factors viz., location of tumor, preference of surgeon, body habits, prior operation, condition of the patient, choice of esophageal substitute and prior radiation.54,55
11
Most of the evidence accumulated from random studies suggests that the use of various modalities of induction therapy provide little or no advantage over primary surgical resection alone.56
Orringer et al57 reported on 800 patients with cancer of the intrathoracic esophagus and cardia treated with transhiatal esophagectomy, adenocarcinoma was present in 69% of cases, where as 28% had epidermoid cancer. Hospital mortality was 4.5%, and morbidity was 27%. Major complication including anastomotic leak (13%), recurrent laryngeal nerve injury, (7%) wound infection (3%), pulmonary complications (2%), bleeding (1%) and chylothorax (1%). More than 90% of the patients were discharged within 21 days of hospitalization. There was an overall statistically significant survival with adenocarcinoma (24%, v/s 17%).
The study by the University of Michigan group represents the largest experience with transhiatal resection for carcinoma and survival rate and morbidity were quite consistent with those reported by other surgeons who practice a similar approach.57,58
Gelfand et al59 reported on 160 patients who underwent transhiatal esophagectomy, the operative mortality and 5 year survival rates were 2% and 21%
respectively.
Gertsch and Colleagues60 described their experiences with 100 patients, hospital mortality was 3%, and morbidity was 68%.
12
Vigneshwaran et al61 reported on 131 patients who underwent transhiatal esophagectomy with 2% operative mortality.
Parker SL, Tong et al have demonstrated pulmonary complications are most common problems encountered in esophagectomy patients. Pneumonia being the commonest smoking cessation preoperatively, adequate pain control with aggressive physiotherapy and early ambulation are cornerstones of preventive therapy.
Gastric advancement is without doubt the best esophageal replacement when esophagectomy in performed for palliation of cancer. The extent of operative dissection and the resultant physiologic insult are less when preparing the stomach for advancement compared with colon.
The hospital recovery and time to return of unrestricted alimentation are also shorter in patients undergoing gastric pull up.62
There was a general belief earlier that a vagally denervated stomach acts like a denervated tube63,64 and the emptying depends on the gravity65 but recent scintigraphic studies ambulatory gastric manometry and video fluoroscope have shown that its motility remains unchanged and the transposed stomach tube acts as a “dynamic conduit”.
Erythromycin is known to enhance the early postoperative contractivity of denervated whole stomach and may be tried if stasis occurs in postoperative period.66
13
Bardini et al have reported anastomotic leak of around 12% regardless of method of suturing. Conduit necrosis is due to ischemia. Anastomotic stricture required dilatation in upto 4% of patients.
Advances in perioperative care including anaesthetic techniques and nutrition have enabled mortality rates for resection of esophageal cancer to fall to between 5% to 10% in experienced hands.67,68
14
SURGICAL ANATOMY4-8
It’s a hollow muscular tube extending from the pharynx to the stomach i.e. from C6-T11. The length is approximately 25 cm.
It commences in the midline, slightly deviates to left upto the root of the neck, returns to the midline at the level T4-T5, at T7 deviates again to the left and pierces the diaphragm at T10.
1. Cervical constriction: 15 cms from incisor teeth at the level of cricopharyngeus.
This is the narrowest part in the GIT.
2. Aortic arch: 22.5 cms from incisor teeth.
3. Left main bronchus: 27 cms from incisor teeth.
4. Diaphragm: 40 cms from incisor teeth.
Anatomical divisions 1. Pharyngesophageal 2. Cervical
3. Thoracic 4. Abdominal
15
Fig. 1: Surgical anatomy of esophagus
Pharyngesophageal: It extends from inferior pharyngeal constrictor to upper esophageal sphincter.
Killian’s dehiscence: It is a potential point of weakness in this segment.
Site pharyngesophageal / Zenker’s diverticulum
Common site of perforation in esophagoscopy.
16
Cervical Esophagus: Extends up to the beginning of T1 measuring 5-6 cms in length. Surgically, more approachable through the left neck incision, as it tends to course more towards left of trachea.
Thoracic esophagus: Passes through the superior and posterior mediastinum.
Below the tracheal bifurcation esophagus curves to the right and lies adjacent to the right pleural cavity. Therefore perforation leads to right pleural cavity. Therefore, perforation leads to right pleural effusion. Below level of T7, esophagus curves towards that left. So perforation of the lower third leads to left pleural effusion.
Abdominal esophagus: Measures 1-2-5 cms in length. IT passes through diaphragmatic hiatus along with vagus nerve and branches of left gastric artery. It is covered with peritoneum on the anterior and lateral surface. It takes a sharp turn to the left on entering the abdomen.
Esophagus is divided into 4 principle regions according to American Joint Committee for Cancer (AJCC) staging:
• Cervical esophagus
• Upper thoracic
• Middle thoracic
• Lower thoracic
17
Most surgeons divide the esophagus into ‘thirds” as follows”:
• Upper third: Cricopharynx to superior portion of aortic arch.
• Middle third: Aortic arch to inferior pulmonary vein.
• Lower third: Inferior pulmonary vein to gastroesophageal junction.
BLOOD SUPPLY
Cervical esophagus: By superior and inferior thyroid artery.
Thoracic esophagus: Mainly supplied by 4-6 aortic esophageal branches.
Lower esophagus: By esophageal branches of left gastric and left inferior phrenic artery.
Fig. 2: Arterial blood supply of esophagus
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VENOUS DRAINAGE
Cervical esophagus: Mainly to inferior thyroid vein.
Thoracic esophagus: Left side – left hemiazygos.
Right side – azygos
Abdominal: Left gastric vein which empties into portal vein.
Fig. 3: Venous drainage of esophagus
19
LYMPHATIC DRAINAGE
There are 2 lymphatic plexuses in the:
1. Mucosa
2. Mucosal layer Flow of lymphatics
1. Upper 2/3- upwards 2. Lower 1/3- downwards Lymph nodes
There are 3 parallel inter connected chains:
1. Paraesophageal 2. Periesophageal 3. Lateral esophageal
20
Fig. 4: Lymphatic drainage of esophagus NERVE SUPPLY
1. Cervical esophagus
• Sympathetic- fibres from superior and inferior cervical sympathetic ganglia.
• Parasympathetic- recurrent laryngeal nerve.
2. Thoracic esophagus
• Sympathetic – upper thoracic and splanchnic nerves
• Parasympathetic – vagus.
3. Abdominal esophagus
• Sympathetic-celiac ganglia
• Parasympathetic–vagus.
The recurrent laryngeal nerve, also supplies cricopharynx, so if there is weakness of the recurrent laryngeal nerve. Patients tend to aspirate while swallowing.
In addition, Meissners and Auerbach plexus provide an intrinsic autonomic nervous system within esophageal wall.
1. Messners plexus-in sub-mucosa.
21
2. Auerbach plexus-connective tissue between longitudinal and circular layers.
Fig. 5: Nerve Supply of Esophagus
24
ETIOPATHOGENESIS
Any study of cancer cannot be done without detailed study of causative factors.
The causative factors can be obtained from a detailed study of diet habits, environmental agents, infectious agents and other factors. The etiologic factors play a very important role in the pathogenesis of upper gastrointestinal tract cancer.
[1] TOBACCO SMOKING AND ALCOHOL
Ernest Wydner and colleagues carried out several studies since 1957 and have shown that the extensive use of alcohol significantly increases the risk of esophageal carcinoma in tobacco users/although alcohol itself does not seem to increase the risk of this cancer.74
But later on Pottern and Colleagues identified tobacco and alcohol as important independent risk factors for esophageal cancer and also established that apart from being independent risk factors, they also exert and synergistic action by potentiating each other.75 The risk is said to increase with increasing number of cigarettes and duration of smoking habit.76
Ribeiro et al in his Study said that the risk of esophageal carcinoma varied with the type of alcohol consumed suggesting that the risk spirits is usually more than twice than from beer and the risk from wine being intermediate between that for beer and spirits.77
25
Similar studies carried out in South India by Chitra et al identified Alcoholism, smoking, and chewing of tobacco as important predisposing for esophageal cancer.78 Studies carried out by Devisor et al indicate that cigarette smokers have 2 to 3 times increased risk of esophageal and proximal gastric center.79
BETELNUT AND BETEL LEAF
Observatory regarding the association of esophageal cancer with betel nut claims were made as early as the 1970s by Stephne et al.80 The chewing of betel nut and betel leaf with or without tobacco is or common practice in certain parts of India. In a study conducted by Nayar et al at the All India Institute of Medical Sciences, the risk of developing esophageal carcinoma increased by 3.16 times with the daily habit of clewing betel leaf and tobacco.28
DIETARY FACTORS
A variety of dietary factors have been implicated in the development of esophageal cancer, because of their distinct variations in incidence and mortality, between countries in different socio-economic groups and in migrants and their offspring’s. The role of diet has been extensively investigated but with in conclusive results.
Nitrosamines
They have been implicated in the development of esophageal carcinoma.
Khuroo et al in their study, found that the Kashmir Province of India is a high risk area for esophageal cancer, where the diet contains substantial amount of N-Nitroso
26
compounds and comprises of Salt tear, dried fish, vegetables (especially brassica abesecar), red abilities and spice cakes.25
Fruits & Vegetables
Rensburg in his study suggested that or chronic low intake of several micronutrients, together with an inadequate protein intake, increases the be disposition of the esophageal epithelium to neoplastic transformation. Diet deficient in vitamins A, C, E, Niacin, Riboglasin and Zinc have been suggested as risk factors.81
Infectious Agents
The infectious agents may be in the form of viral, bacterial or fungal organisms.
1. Viral Agents: The Viruses that have been implicated is Human Papilloma virus (HPV) for esophageal cancer. Toh et al found an association between HPV infection and development of esophageal cancer.82
2. Fungal agents: These have been implicated as etiological agents in malignancies of esophagus. Bhatior et al in their study isolated fungi in 75% cases of Carcinoma esophagus and the most common species over candida albicans, species.83
Genetic Factors
The risk of esophageal cancer is found to be more among first degree relatives.
Pour et al in their study found that the risk of developing esophageal cancer among blood relatives was higher.84 However, no specific genetic factors have been identified.
27
Low Socio-economic Status
Several studies, carried out by Enzinger et al proved that low socioeconomic status is associated with an increase risk of esophageal.
Predisposing lesions
The risk for SCC esophageal Carcinoma include; Achalasia, Caustic injury to esophagus, tylosis, plumervision syndrome84 and Barrett’s esophagus.
Clinical Course and Prognosis
The clinical course and prognosis of esophageal cancer depends chiefly on the extent of local strand, lymph node involvement and metastasis.
Esophageal Cancer
The overall prognosis for esophageal carcinoma is very poor with 5 year survival of around 10% 15%. In esophageal carcinoma, Metastasis to lymph node is very common because of the rich lymphatic supply of the esophagus, especially to the periesophageal areas, below the diaphragm and upward to the cervical nodes.
Distant metastasis can occur to lung, liver and adrenal glands.85 Esophageal cancer is classified according to the 2002 American Joint Committee on Cancer – tumor node metastasis (TNM) Classification system, which takes into account the characteristics of the Binary tumour, regional lymph node. Metastasis and digital metastasis more than 50% of patients have unresectable or metastatic disease at the time of presentation.86
28
TRANSHIATAL ESOPHAGECTOMY
Operative steps
In an otherwise, fit patient subtotal resection of esophagus with esophageal gastric anastomosis at the neck level should be the sensible, approach of achieving best form of palliation. For this removes the near total esophagus, reducing the recurrence rate and restoring their swallowing act. This goal is achieved with admirable success rate by Transhiatal esophagectomy (THE) as compared to other approach, which is known for higher morbidity and mortality. If there is an anastomotic leak patients do not end up with mediastinitis. It is easily managed by drainage and wound care. The patient will be fit for discharge within 2 weeks after THE. Few cases are also gifted with a bonus of cure.
Transhiatal esophageal resection
It is usually done synchronously by 2 teams of surgeons, one operating per abdomen and the 2nd surgeon exposing the cervical esophagus.
Procedure
Incision from xiphisternum to 2-3” below the umbilicus. Liver, retrogastric celiac nodes, spleen, stomach and the entire intestine are seen and palpated. In growth, involving the lower esophagus and cardia the mobility of tumour is ascertained.
29
Steps by the abdominal surgeon
1) The greater curvature of the stomach is freed from its omental attachment by dividing the omentum outside the gastro epiploic arch. Short gastric vessels are ligated midway between stomach and the spleen, curved fundic dome is released by diathermy coagulation applied well clear of the viscera.
2) Posterior wall of stomach is exposed and any adhesions are diathermy divided under vision.
3) Lesser omentum is divided upto the hiatus, preserving the right gastric artery.
4) With the assistant firmly retracting the pancreas the left gastric vessels are made taught and double ligated individually. The posterior dissection is carried proximally upto the hiatus.
5) Duodenum is Kocherised.
6) The hiatus is widened by dividing the crura of the diaphragm keeping in mind the proximity of IVC and hepatic veins.
7) The index and middle finger are insinuated into the posterior mediastinum, the growth proper is palpated, limits ascertained and nodes if any palpated. The esophagus is freed from the vertebrae by gentle finger dissection. Posterior vagus hooked and divided. Next the esophagus is freed on the right and left sides. The anterior vagus is hooked and divided, the fingers are carried anteriorly and the distal esophagus with the growth is mobilized all around. When the major part of esophagus is mobilized one should carefully palpate the tracheal bifurcation and the main bronchi and avoid injuring them. At this stage the surgeon’s right hand is completely within the thoracic cavity.
30
During mobilization of thoracic segment of esophagus there is likely to be venous return impediment, and fall in BP or even arrhythmia. The anaesthetist is to monitor the BP and Pulse, whenever the systolic BP falls below 60 mm of Hg, the hand is withdraw and within a few minutes the BP recovers to everyone’s delight. Thus blunt mobilization of thoracic esophagus is an intermittent procedure, the timing dictated by the anaesthetist.
Also at the time of blunt mobilization the anaesthetist switches onto hand ventilation so that any inadvertent injury to the tracheobronchial tree is immediately recognized.
Once the abdominal surgeon begins to mobilize the esophagus and gives the go ahead sign another surgeon being to expose the cervical esophagus.
By the time abdominal surgeon have mobilized upto the tracheal tree the other surgeon would have mobilized the cervical esophagus and upper thoracic esophagus by blunt dissection.
9) At this state it is easier for the abdominal surgeon to put his left index of middle finger from above and feel his right hand fingers from below.
Thus, he is confident of good all around mobilization.
10) Once the esophagus is divided at the neck, the entire esophagus with the growth is pulled down through the laparotomy wound.
11) The specimen and the stomach are carefully palpated. The stomach is transected 6 cm distal to the lesion along a line extending from low down in lesser curve (including the left gastric nodes) to the top of fundus.
31
12) The stomach is reconstructed into a conduit with staplers. Careful attention is paid in maintaining the vascularity of the gastric conduit especially at the angle of sorrow in the lesser curve.
13) The loose thread lying in the posterior mediastinum is stitched to the stomach and gently pushed up the post mediastinum rather than being pulled by the silk at the neck end.
14) Feeding jejunostomy (Witzel type) is done as a routine about 12 cm distal to the D. J. junction.
Stomach
Stomach is the referred viscus to replace esophagus because of:
1. Single anastomosis 2. Easy mobilization
3. Reliable and consistent blood supply
4. Physiological function of receptive relaxation and adaptive accommodation retained
5. Less chance of anastomotic leak
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Steps in mobilization of cervical esophagus
1. Incision along the anterior border of left sternomastoid muscle.
2. Greater auricular and accessory nerves are preserved.
3. Middle thyroid vein is ligated and divided.
4. Thyroid gland pushed medially by the assistant fingers rather than by a retractor and the greater vessels are retracted laterally.
5. Recurrent laryngeal nerve safeguarded.
6. Esophagus mobilized by blunt dissection and tape passed around it.
7. With traction on the tape the distal part is gently mobilized by blunt finger dissection, keeping in mind the proximity of brachiocephalic vein, left common carotid artery and aorta.
8. After all round mobilization the esophagus is transfixed with a long thick silk as low down as possible and divided proximal to the stitch. The distal cut end of the esophagus is pushed down the mediastinum for the abdominal surgeon to pull out the specimen per abdomen. After the stomach is pulled down the long silk will remain in the posterior mediastinum with the free end lying in the neck. This is used to pull up the reconstructed gastric tube as the case may be.
9. Once the reconstructed gastric tube pulled upto the neck the surgeon ascertains that the viscera is not rotated and its vascularity is well maintained.
10. An end to side single layered interrupted anastomosis is done 3 0’ PDS. The wound closed with a drain.
33
Complications: Variety of iatrogenic complications of vital structures in close proximity to the esophagus can occur. Some of them e.g., tracheal tear, aortic tear, may end up in death on table. Knowledge of anatomy, avoiding aggressive mobilization of esophagus by keeping fingers close to the esophagus (Ryle’s tube inside the esophagus helps) and willingness to perform thoracotomy in difficult mobilization will reduce the rate of complication. Acute myocardial problem may also result in death on table.
PREOPERATIVE A. Neck level
1. Injury to recurrent laryngeal nerve
During mobilization of cervical esophagus recurrent laryngeal nerve (RLN) may be injured either by traction or transaction. The result may vary from hoarseness, coughing, vocal cord paralysis which may lead to aspiration. Bilateral vocal cord palsy may need re-intubation or tracheostomy. Using finger of the assistant instead of retractor to retract the thyroid will reduce the incidents of injury to RLN. Since the esophagus lies a little to the left of midline, left side exposure will reduce the injury to RLN. By keeping close to the esophagus while passing the tape right nerve will be safe guarded.
2. Injury to blood vessels
The jugular vein and middle thyroid vein may be injured in the neck.
34
B. In chest cavity
1. Injury to tracheobronchial tree
Preoperative bronchoscopy is mandatory before esophageal surgery to rule out any infiltration. Tracheobronchial tree injury occurs more commonly after THE. The finger dissection should be kept close to esophagus. The volar aspect of the left index finger passed through the neck guards the trachea, while the right fingers passed through the hiatus dissects the esophagus from the tracheobronchial (TB) tree. The tear may also occur due to over insufflation of the cuff. Injury can be recognized by anaesthetist by the fact of tightness of the bag. Injury will result in inadequate ventilation and drop in saturation and blood pressure. Instead of over ventilation the tubes should be carefully advanced into the left bronchus and patient prepared for thoracotomy. Small injuries can be directly sutured whereas loss of tracheal tissue may be buttressed with pleural flap or a pericardial flap. Postoperatively ventilation has to be monitored.
2. Tear of azygos vein
After ligation of the left gastric artery and inferior thyroid artery, esophagus receives its blood supply from small branches from aorta which form sub mucosal plexus.
When these vessels are torn the vessels contract and the bleeding stop. If during mobilization in THOR, there is a continuous bleeding and steady fall in BP, azygos vein tear should be suspected and the mediastinum should be packed immediately and the thoracotomy performed to visualize and suture the azygos vein.
35
3. Opening of pleural cavity
This invariably occurs in THE and sometimes can result in tension pneumothorax and if so immediate chest drainage tube should be positioned.
4. Injury to aorta
It is rare injury but it can result in awesome bleeding and could end up in death on table before thoracotomy could be done.
C. Abdominal cavity
1. Inadequate blood supply to the transposed viscera
When the stomach is used as the conduit the blood supply is maintained by right gastric and gastroepiploic artery. These vessels should not be subjected to twisting or extrinsic compression which may result in poor fundal perfusion, venous congestion and possibly anastomotic break down. The conduit should be transposed into the posterior mediastinum by a gentle push from the abdomen rather than pull at the neck level.
Volvulus of the transposed stomach can occur. After transposition the stomach lies in the mediastinum with 180 degree rotation, the greater being rotated anteriorly. If the stomach rotates through 360 degree than gastric outlet obstruction are even sloughing of the conduit occur.
Before transposing the stomach venous congestion of the site to the anastomosed at the neck should be eliminated for this may later interfere with arterial perfusion and result in breakdown of anastomosis.
36
In the postoperative period unexplained fever, tachycardia, leucocytosis and discharge from the neck should alert the physician of breakdown in anastomosis. If confirmed excision of the sloughed graft and cervical esophagectomy is the choice. Later substernal colonic transposition may be considered.
2. Injury to spleen, liver and pancreas
Splenic injury could be prevented by avoiding undue traction during greater curvature mobilization. Small tear from adhesions may be controlled with packing.
Bigger lacerations better dealt with splenectomy. Liver and pancreatic injuries are less often encountered and easily preventable.
3. Hiatal herniation
Herniation of the abdomen content through the divided hiatus can occur even after many years. Uncomplicated hernia can remain asymptomatic. When the patient develops chest pain respiratory distress, fever, leucocytosis, flat but rigid abdomen, obstruction or strangulation should be suspected. Immediate surgery either by abdominal or thoracic route should be undertaken.
If at operation hiatus is considered to be very wide it may be sutured to the conduit without jeopardizing the vascular integrity.
37
Postoperative: Early complications
Hoarseness: Due to recurrent laryngeal nerve involvement and usually improves in 6 weeks time. Intubation trachitis may also cause temporary hoarseness, short course of steroid will help.
Anastomotic leakage: The incidence of anastomotic leaks various widely and has been reported upto 53%. Vigneswarn et al classified anastomotic leakage into 3 types.
Type 1: Silent clinically or discovered by the contrast study, usually heal spontaneously without any stricture formation.
Type 2: Leak with systemic disturbances like fever, pain, leucocytosis, discharges from the wound. Given time it will heal with wound care and antibiotics. May result in a stricture.
Type 3: Leak due to ischemia and necrosis at the anastomotic site. May require exploration and cervical oesophagostomy and later colonic transposition.
Bruce et al in their review article proposed to use the definition as suggested by the surgical infection study group, a UK multidisciplinary group.
38
Definition of leak as adopted from the surgical infection study group87
Leak Definition Treatment
Radiological No clinical signs No change in management Clinical minor Local inflammation,
cervical wound X-ray contained leak (thoracic anastomosis) Fever, WBC, CRP
Drain wound Delay oral intake antibiotics
Clinical major Severe disruption on endoscopy, Sepsis
Change management CT guided drainage (Reintervention)
Conduct necrosis Endoscopic confirmation Reintervention
Absence of serosal coat, tension at the anastomotic site due to imperfect or inadequate mobilization of the stomach conduit, compression of the conduit at the substernal level which may affect its vascular integrity, are the local factors contributing to anastomotic leak. Systemic disease like diabetes, tuberculosis, cirrhosis of the liver, preoperative irradiation etc., may also contribute to poor healing and anastomotic leakage.
Leakage in the mediastinum after intrathoracic anastomosis have high morbidity and mortality. Immediate drainage of the chest cavity should be done along with appropriate antibiotic. Reoperation to establish the continuity of the GI tract have high rate of morbidity.
39
Chylothorax
Uncommon complication but can result in nearly 50% mortality if left unrecognized. Patients who had neoadjuvant RT and patients with the adherent tumour the thoracic duct is more like to be injured. If there is an excessive discharges of milky fluid from the ICD chylothorax should be suspected. Estimation of triglyceride and chylomicron in the drainage will clinch the diagnosis. Excessive drainage for long time result in nutritional deficiency. Once recognized re-exploration and the ligation of the duct should be done.
Aspiration: While swallowing liquids in the early stages. This may lead to fulminate pulmonary complication.
Necrosis of the transposed stomach in the mediastinum: The patient is usually toxic with respiratory distress, leucocytosis etc. early recognition and re operation is the only change of survival. At surgery the gastric conduit is dismantled, vascular integrity ascertained and if the conduit if found to be ischemic that segment is transected and substernal colonic bypass done.
Pulmonary complications: More common with transthoracic resection.
Complications may range from pneumonia to respiratory failure. Patients with preoperative uncompromised respiratory diseases are more prone to develop pulmonary complications. Preoperative radiotherapy, chemotherapy also pre dispose to pulmonary complication.
40
Reflux of gastric contents: This may lead to aspiration and pulmonary complications. Reflux of gastric contents is more common after intrathoracic anastomosis compared to cervical anastomosis. The addition of pyloric dilation helps to certain extent in preventing the reflux. Keeping the Ryle’s tube in the early post operative period and aspiration also minimizes chances of aspiration.
Late complications
Stricture at anastomotic site: This may present early or even after few months or years. Early anastomotic leak and wound healing by fibrosis predispose to stricture formation. The incidences are more common after stapled anastomosis compared to hand sewn anastomosis. Quite often these patients can be managed with regular dilatation using a balloon dilator. With delayed occurrence of stricture one should suspect recurrence at the anastomotic site.
Recurrence of tumour Anastomotic recurrence
With T4, N1 status with venous permeation, in intrathoracic anastomosis when less then 10cms of the esophagus is removed and missing skip lesions recurrence is more common.
Loco-regional recurrence
41
With adherent tumour and incomplete clearance at esophageal bed predispose to loco regional recurrence. Such patients are in a poor state of health not suitable for chemoradiation.
Fig. 6: Mobilisation of the stomach
42
Fig. 7: Preparation of gastric conduit
Fig. 8: Mobilisation in the neck
44
Patients were selected from those presenting to the OPD and those referred from elsewhere.
As mentioned earlier, all fresh patients biopsy proven carcinoma of the esophagus were included in the study. The following patients were however excluded from the study:
(a) Inoperable patients,
(b) Patients with history of previous chemotherapy, radiotherapy or esophageal surgery,
(c) Non-ambulatory patients, and
(d) Patients having malignancy of upper third of esophagus.
1. The cases of carcinoma esophagus which were confirmed by relevant investigations were subjected to surgery. Operative findings and postoperative findings were recorded.
2. There were 30 patients of which 20 were male patients and 10 female patients with age ranging from 40 to 87years.
3. The indication for surgery is mainly palliation to relieve pain and dysphagia.
4. Depending upon the operability, stage of the disease cases were selected.
5. Preoperative evaluation included history and physical findings. UGI endoscopy and biopsy, ultrasound abdomen and CT abdomen were done.
45
6. The evaluation criteria used were selected on the basis of availability of resources in our setup, with the aim of using the minimum possible investigation to achieve the diagnosis and provide optimum treatment.
7. Most of the patients were shifted to postoperative wards except for few patients who were shifted to ICU immediately after surgery.
8. Laboratory investigation done in each case included:
a. Complete haemogram b. Coagulation profile
c. Base line renal function serum creatinine, electrolyte, urine routine and microscopy.
d. Routine chest roentgenograms were done in all the cases.
Diagnostic Investigation done included:
1. Upper GI Endoscopy: The Olympus flexible video endoscope was used for all patients for diagnostic purposes.
2. Endoscopic biopsy was done for all the patients and the diagnosis was confirmed by histopathological examination.
3. U/S abdomen was also done in all the patients.
4. C-T abdomen: To know the infiltration into surrounding structures, the liver secondaries or any other secondary nodal deposits.
46
5. Pulmonary function tests: In case of patients with pulmonary disease and in smokers and tobacco chewers to plan anaesthesia and for better post operative rehabilitation.
Surgical treatment
All the patients underwent elective surgery after the correction of anemia, improvement of nutritional status, and after thorough preoperative preparation. Vigorous chest physiotherapy by experts was given in the preoperative and postoperative phases.
Board spectrum antibiotics were given to all patients preoperatively, perioperatively and postoperatively.
47
Operative steps
In an otherwise fit patient subtotal resection of esophagus with esophageal gastric anastomosis at the neck level should be the sensible approach of achieving best form of palliation. For this removes the near total esophagus, reducing the recurrence rate and restoring their swallowing act. This goal is achieved with admirable success rate by Transhiatal esophageal resection (THE) as compared to other approach, which is known for higher morbidity and mortality. If there is an anastomotic leak patients do not end up with mediastinitis. It is easily managed by drainage and wound care. The patient will be fit for discharge within 2 weeks after THE. Few cases are also gifted with a bonus of cure.
Compulsorily corrugated drains were kept for all the patients in the neck near the anastomosis.
Postoperatively patients were given intense monitoring, and all were closely monitored for development of complications.
Intercostals drain were kept in all the patients in whom pleura was damaged.
Monitoring vital signs of temperature, pulse, respiratory rate, blood pressure, ECG, monitoring fluid balance, acid base balance, biochemical and hematological monitoring.
48
Postoperative chest X-ray film to check position of inter costal drainage tubes, central venous pressure line and to know lung expansion.
Adequate pain control, using narcotic analgesics through either, intravenous, intramuscular or epidural route and non steroidal anti-inflammatory drugs.
Ventilator care and endotracheal tube care with intermittent suctioning to prevent aspiration of bronchial secretions.
After checking lung expansion and if the acid base studies and biochemical parameters are within acceptable limits patients is extubated.
Nasogastric tube is maintained to minimize gastroesophageal reflux and aspiration and is removed when it is no longer required, usually on the fourth postoperative day.
Maintenance of intercostal drainage tube in proper position with underwater seal or negative suctioning (usually the drains are removed after the drainage becomes minimal)
Neck drain is removed after starting the patient with oral liquids to prevent wound infection and to detect leak.
Maintaining good oral hygiene to prevent oral infection, which can cause suppurative infection.
49
Maintaining good general hygiene and proper positioning to prevent pressure sores.
Total parenteral nutrition supplementation according to the requirement of the patient.
Jejunostomy feeding
Usually started after 48 hours after surgery when the bowel starts moving actively. Feeding is started with clear fluids and gradually changed over to liquid diet.
Commercial formula preparations available can also be used, the usual requirement being around 2500 kcals per day.
Venous thromboembolism
Prophylaxis with administration of subcutaneous heparin or low molecular weight heparin, anti-embolism stockings and early ambulation.
Physiotherapy
Physiotherapy with postural drainage, percussion and vibration with breathing exercises to improve the lung function and encouraging the patient to cough out bronchial secretions was done by an experts.
• Passive leg exercises to prevent Deep Venous Thrombosis.
• Wound care.
• Patient is monitored in the postoperative intensive care ward for 24 hours after extubation.
50
Late postoperative care
Implying the importance of maintaining good general hygiene.
Oral feeding is started with soft solids in sitting position dietary intake is gradually liberalized with emphasis being placed on small frequent feeds as patient will experience fullness in early stages after operation.
Jejunostomy tube is usually retained in situ till the completion of chemotherapy for maintaining nutrition as the patient may experience vomiting during this period.
Jejunostomy wound care.
Discharge
The criteria for discharge are:
1. Adequately healed abdominal and neck incisions.
2. Maintenance of normal vital parameters
3. Repeat U.G. scopy after 12 days and if there are no anastomotic abnormalities in form of stricture / dehiscence.
52
Fig. 10: Bar graph showing age distribution
The highest incidence was observed in 5th and 6th decade of life, patient aged ranged from 40 years to 87 years.
66
Fig. 21: Bar graph showing blood group among patients studied
Most of the patients (73.3%) belonged to either blood group A or blood group O.
