surgical procedures for esophageal cancer

1. By: OLAJUYIGBE GBOLAHAN
Saratov State Medical University

2.  Hollow muscular tube 25 cm in length which
spans from the cricopharyngeus at the cricoid
cartilage to gastroesophageal junction (Extends
from C7-T10).
 Has 4 constrictions-
 At starting(cricophyrangeal junction)
 crossed by aortic arch(9’inch)
 crossed by left bronchus(11’inch)
 Pierces the diaphragm(15’inch)
 Histologically 4 layers:
mucosa, submucosa, muscular &
fibrous layer.

3. Four regions of the esophagus:
 Cervical = cricoid cartilage to thoracic inlet (15–18 cm from the incisor).
 Upper thoracic = thoracic inlet to tracheal bifurcation (18–24 cm).
 Midthoracic = tracheal bifurcation to just above the GE junction (24–32 cm).
 Lower thoracic = GE junction (32–40 cm).

5.  Rich mucosal and submucosal
lymphatic system.
 The submucosal lymphatics may
extend long distances.
 The submucosal plexus drains into
the regional lymph nodes in the
cervical, mediastinal, paraesophageal,
left gastric, and celiac axis regions

6. • Esophageal intraepithelial neoplasia
• Glandular epithelial dysplasia/adenocarcinoma in situ in Barrett's
mucosa
Preinvasive Neoplasia
• Squamous cell carcinoma
• Adenocarcinoma,
• Adenoid cystic carcinoma
• Mucoepidermoid carcinoma
• Adenosquamous carcinoma
• Small cell carcinoma
• Carcinoid tumor
• Malignant melanoma
• Sarcomas
Invasive Malignant Neoplasia
95%

7.  Esophageal cancer is the 7th leading cause of cancer deaths.
 accounts for 1% of all malignancy & 6% of all GI malignancy.
 Most common in China, Iran, South Africa, India and the former Soviet Union.
 The incidence rises steadily with age, reaching a peak in the 6th to 7th decade of life.
 Male : Female = 3.5 : 1
 African-American males : White males = 5:1

8.  Worldwide SCC responsible for most of the cases.
 Adenocarcinoma now accounts for over 50% of esophageal cancer in the USA, due to
association with GERD , Barretts’s esophagus & obesity.
 SCC usually occurs in the middle 3rd of the esophagus (the ratio of upper : middle :
lower is 15 : 50 : 35).
 Adenocarcinoma is most common in the lower 3rd of the esophagus, accounting for over
65% of cases.

9.  Smoking and alcohol (80% - 90%)
 Dietary factors
 N-nitroso compounds (animal carcinogens)
 Pickled vegetables and other food-products
 Toxin-producing fungi
 Betel nut chewing
 Ingestion of very hot foods and beverages (such as tea)
 Underlying esophageal disease (such as achalasia and caustic strictures,
Tylosis)
 Genetic abnormalities:
 p53 mutation, loss of 3p and 9q alleli

10.  Associated with Barretts’s esophagus, GERD
& hiatal hernia.
 Obesity (3 to 4 fold risk)
 Smoking (2 to 3 fold risk)
 Increased esophageal acid exposure such as
Zollinger-Ellison syndrome.
Barrett’s esophagus is a
metaplasia of the esophageal epithelial lining.
The squamous epithelium is replaced by
columnar epithelium,with 0.5% annual rate of
neoplastic transformation.

11. A- Annular type: more common in lower 1/3.
B- Ulcerative type: raised everted edge- necrotic
floor- indurated base
C- Cauliflower type (60%): fungating mass.
A B C

12.  No serosal covering, direct invasion of contiguous structures occurs early.
 Commonly spread by lymphatics (70%)
 ** Cervical esophagus → lower deep cervical L.N.
 ** Thoracic esophagus → para-oesophageal & tracheo-bronchial lymph nodes
 ** Abdominal esophagus → lymph nodes along the lesser curvature of the stomach → coeliac axis L.N.
 Lymph node involvement increases with T stage.
 T1 – 14 to 21%
 T2 – 38 to 60%
 25% - 30% hematogenous metastases at time of presentation.
 Most common site of metastases are
 lung, liver, pleura, bone, kidney & adrenal gland
 Median survival with distant metastases – 6 to 12 months

13. PRIMARY TUMOR
 Tx → Primary tumor cannot be assessed
 TO→ No evidence of primary tumor
 Tis→ Carcinoma in situ
 T1 → Tumor invades mucosa or submucosa
 T2→ Tumor invades musculosa
 T3→ Tumor invades adventitia.
 T4→ Tumor invades adjacent structures.
REGIONAL LYMPH NODES
 Nx→ Regional nodes cannot be assessed
 NO→ No regional node metastasis
 N1 → Regional node metastasis
DISTANT METASTASES
 Mx→ Presence of distant metastasis cannot be assessed
 MO→ No distant metastases
 M1 → Distant metastasis

14.  DYSPHAGIA: Cardinal symptom, characterized by;
 Onset: Late onset
 Course: Continuous and progressive course
 Duration: Short duration (few months).
 First to: solid but not to fluids, later to both fluids & solids
 Associated with: very bad general condition
• REGURGITATION: Regurgitation is effortless while vomiting is forcible.
• PAIN: Usually a late manifestation.
• Wt. loss – more than 5 % of total body wt. in 40 – 70% pt. associated with worst prognosis.

15.  Cachexia, Malnutrition, dehydration, anemia,.
 Aspiration pneumonia.
 Distant metastasis.
 Invasion of near by structures: e.g.
 Recurrent laryngeal nerve → Hoarseness of voice
 Trachea → Stridor & trachea/esophageal fistula→ cough, choking & cyanosis
 Perforation into the pleural cavity → Empyema
 back pain in celiac axis node involvement

16.  Detailed history & Physical examination: Dysphagia, odynophagia, hoarseness, wt.
loss, use of tobacco, nitrosamines, history of GERD. Examine for cervical or supraclavicular
adenopathy.
 Barium Swallow
a.Fungating and ulcerative mass: narrowed irregular filling defect.
b.Annular mass:
 - If middle stricture: Apple core appearance with evident shouldering
 - If lower stricture: Rat tail appearance.

17. Rat tail
appearance
Apple core
appearance

18. Cancer lower 1/3
Filling defect (ulcerative
type)

19.  Confirmation of diagnosis:
 Esophagoscopy: allow direct visualization and biopsy, measure proximal & distal distance of tumor
from incisor, presence of Barrett’s esophagus.
Early, superficial
cancer
Circumferential ulceration
esophageal cancer
Malignant stricture of
esophagus

20. Lung: chest x-ray & C.T
Liver: US
Bone: Bone scan & Bone survey
Brain: C.T.

21.  Endoluminal endoscopic ultrasound: to detect wall penetration and regional LN
status.
 CT and MRI Scan
T4 esophageal cancer

22.  most recently, proven to be valuable staging tool
 can detect up to 15–20% of metastases not seen on CT and EUS
 low accuracy in detecting local nodal disease compared to CT / EUS
 Value in evaluating response to Chemo Therapy & Radio Therapy
 addition of PET to CT can improve specificity and accuracy of non-
invasive staging
Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A, Integrated CT
PET demonstrates para-aortic lymph node metastases showing increased FDG uptake (arrowheads). B,
Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in diameter. Based on size
criteria, these lymph nodes may be considered benign on CT scan

23.  Site of disease
 Extent of disease involvement
 Co-morbid conditions
 Patient preference.
Prerequisite for surgery
disease should be 5 cm beyond cricophyrangeus.
Surgery indications
Lower 1/3rd esophageal ds involving GE junction.
Tumor size <5 cm .

24. Operable Inoperable
Radical surgery followed
by chemoradiotherapy
Palliative procedure

25. Unfit patient
Presence of distant metastases
Unresectable tumor
Infiltration of important structure as
trachea, aorta
CRITERIA OF
INOPERABILITY

27.  Transhiatal esophagectomy is performed
in 4 phases.
 Initially, the abdomen is opened and
assessed for metastasis and resectability.
The stomach is mobilized in preparation
for resection.
 In the second phase, the esophageal
hiatus is widened and mediastinal
esophagus is mobilized.
 In the third phase, through a cervical
incision, the cervical esophagus is
mobilized and upper mediastinal
dissection is performed.
 Finally, the esophagus is resected and a
stomach tube created. The stomach tube
is brought up in the neck and
esophagogastric anastomosis is done.
Mobilization of Stomach
Cervical
Incision

28. Creation of Stomach tube
Mobilization of
Cervicothoracic esophagus
Exposure of
Cervical
esophagus

29.  The Ivor Lewis esophagectomy is appropriate
for tumors of the distal esophagus and
gastroesophageal junction
 A two-stage procedure. The first stage
consisted of a laparotomy and mobilization of
the stomach, and the second stage was a right
thoracotomy, resection of the esophagus, and
esophagastric anastomosis.
 The advantages of the Ivor Lewis
esophagectomy include excellent visualization
of all parts of the operation, ability to perform
two-field lymphadenectomy, lower leak rate,
and lower chance of injury to the recurrent
laryngeal nerves.

30. The esophagus is encircled with a large penrose drain.
The lower esophagus can be mobilized under direct
vision transhiatally to confirm resectability of the
tumor. The hiatus is enlarged to fit four fingers

32. With care to
preserve proper
orientation, the
stomach is
delivered
through the
hiatus into the
chest.

34.  Esophageal resection through a left thoracotomy is less commonly used than the Ivor
Lewis procedure or transhiatal esophagectomy.
 When esophagectomy is performed through a left thoracotomy, either posterolateral
thoracotomy or a thoracoabdominal incision may be used.
 After mobilization and resection of the lower half of the thoracic esophagus,
reconstruction is performed in the mediastinum or, preferably, in the neck between the
remaining portion of the esophagus and the gastric fundus.
 A left thoracotomy provides free access to the esophagus from the level of the aortic arch
to the hiatus. This procedure is usually performed for distal esophageal and
gastroesophageal lesions. Although less popular than either the Ivor Lewis approach or
transhiatal esophagectomy, it continues to be useful in the treatment of esophageal or
gastric tumors near the gastroesophageal junction.

35. Drawings illustrate transthoracic esophagectomy through a left thoracotomy. Drawing a
shows how the thorax is usually entered through the left sixth intercostal space. To further
expose the esophagus, the incision may be extended posteriorly (as in posterolateral
thoracotomy). The incision may be extended anteriorly across midline or inferiorly as a midline
incision. Drawings b and c show how resection of the lower esophagus and cardia is performed
with end-to-side esophagogastrostomy.

36. 1 2 3
1. stomach, 2. right or left colon, 3. jejunum. Other options include; revascularized grafts and gastric
tube

37.  1. LASER tunneling with endoluminal stenting
 2. Photodynamic therapy
 3. Intubation
 4. Gastrostomy for feeding

38. Patients may be intubated with
expandable metallic stents, which can be
deployed by endoscopy under fluoroscopic
guidance and can keep the esophageal
lumen patent. Stents are particularly
useful for patients with a
tracheoesophageal fistula.

42. Very bad (5 year survival
rate 5%) due to:
1- Old age
2- Bad general condition before operation
3- Early local spread
4- High morbidity after operation e.g.
empyema, leakage from anastomosis