Carcinoma esophagus is the common cause for dysphagia for solids. These patients usually present too late to do any definitive curative surgical procedure.

1. Carcinoma of Esophagus
Dr.B.Selvaraj MS;Mch;FICS;
Neonatal &Pediatric Surgeon
Melaka Manipal Medical College
Melaka Malaysia

2. Surgical Anatomy :

3. Arterial Supply :

4. Venous Drainage :

5. Lymphatic Drainage :

6. Epidemiology
Sixth most common malignancy world-wide.
Male : Female 4 : 1.
Most common type SCC. Usually affects the upper
2/3rd.
Incidence of Adenocarcinoma is increasing. Usually
affects the lower 1/3rd.

7. Etiology
Dietary
Nitrates.
Fungal toxins in pickled vegetables.
Micronutrient deficiency (Vit. A, B12, C, E).
Trace Element deficiency (Cobalt, Copper Selenium).
Acquired
Cigarette smoking.
Alcohol.
Chronic esophagitis.
Chroinc Dysphagia.
Barrett esophagus.
Achalasia
Lye Corrosive Stricture.
Hereditary

8. Classification
Epithelial:
Squamous Cell Ca.
Adeno Ca.
Adenosquamous Ca.
Mucoepidermoid Ca.
Adenoid Cystic Ca.
Small Cell Ca.
Undifferentiated Ca.
Non – Epithelial:
Leiomyosarcoma.
Malignant Melanoma.
Rhabdomyosarcoma.
Malignant Lymphoma.

9. Clinical Presentation
Dysphagia 87-95%.
Weight Loss 42-71%.
Vomiting/Regurgitation 29-45%.
Pain 20-46%.
Cough/Hoarseness 7-26%.
Dyspnoea 5%

10. Patient Evaluation
Chest X – Ray.
Barium esophagogram.
Endoscopy.
Endoscopic Ultrasound.
C.T. Chest and upper Abd.
Bronchoscopy.
Minimally Invasive Surgical Staging
Thoracoscopy.
Laparoscopy.
MRI / PET Scan.

11. Chest X - Ray
Dilated Esophagus.
Air-Fluid level in esophagus.
Tracheal Deviation.
Mediastinal Soft Tissue Mass – Hilar LN.
May be normal even if disease is advanced.

12. Barium Swallow
74-97% sensitive in detecting growth.
Determine Location Length of tumour.
Identifies TEF.
Detects other deformities in advanced disease.
Tortuosity.
Angulation.
Deviation.
Shows irregular stricture with shouldered
margins.

13. Endoscopy
Allows direct visualisation of the
tumour and Biopsy.
Disadvantage :
Miss early mucosal and submucosal lesion.
No information on radial extension.
Vital staining on endoscopy
(Lugols Iodine, Toluidine Blue)
facilitates early detection of
tumour.

14. Endoscopy- In Situ Ca

15. Bronchoscopy
To assess invasion of
Tracheo- Bronchial tree.
To assess vocal cord
paralysis due to infiltration
of Recurrent Laryngeal N.

16. ENDOSCOPIC USG
Highly sensitive in determining locoregional disease
Useful in staging the tumour.
Accuracy in determining T- Stage is 85% and for N-Stage
75%.
Inability to stage advanced stenotic lesions where
scope cannot be negotiated beyond growth.

17. ENDOSCOPIC USG

18. ENDOSCOPIC USG
TUMOR ESOPHAGUS

19. C.T. Scan
Scans needed for Thorax and Upper Abdomen.
Stage Loco-regional as well as Metastatic Disease.
Can stage advanced stenotic lesions where EUS is
not possible.
Limitation:
Tissue diagnosis not achieved.

20. C.T. Scan- Chest

21. C.T. Scan- Abdomen

22. PET Scan

23. Minimal Invasive Staging
Includes Thoracoscopy and Laparoscopy.
Highly accurate in evaluating N M Status.
Right sided thoracoscopy is usually done.

24. Accuracy of Staging Techniques
Modality T Accuracy
%
N Accuracy
%
M Accuracy
%
C.T. 49-60 39-74 85-90
E.U.S. 76-92 50-88 66-86
Thoracoscopy /
Laparoscopy
- 90-94 -

25. TNM Staging :

26. AJCC Staging :
Stage I T1 N0 M0
Stage II A T2,T3 N0 M0
Stage II B T1,T2 N1 M0
Stage III T3,T4 N1 M0
Stage IV Any T Any N M1

27. Treatment Modality
Operative
Radiotherapy
Chemotherapy
Others :
Intubation
Laser therapy
Photodynamic therapy
Electro – cauterisation

28. Management of Ca esophagus

29. Operative Procedures
Resection:
Pharyngo-laryngo-esophagectomy.
Three phase esophagectomy.
Ivor-Lewis operation.
Transhiatal esophagectomy.
Esophagectomy (Lt. Thoracotomy).
Minimally Invasive Surgery.
Bypass:
Colonic Bypass.
Jejunal Bypass.

30. Pharyngo-laryngo-esophagectomy
Of historical significance only.
For Ca. Cervical Esophagus.
Includes partial pharyngectomy, total esophagectomy
and Laryngectomy.
Needs reconstruction of esophagus.
Presently Radiotherapy is the preferred mode of
treatment, since it preserve voice.

31. Transhiatal Esophagectomy
No thoracotomy
Blunt esophageal resection through hiatus and left
cervical incision
Complete thoracic oesophagectomy
Cervical anastomosis
Less complete lymph node dissection
Intra-operative complications may require
thoracotomy

32. Transhiatal Esophagectomy
Upper Midline Incision
Mobilization of Stomach
Oesophageal Hiatus Enlarged
Blunt Dissection of Thoracic
Esophagus

33. Left Cervical Incision
Blunt Dissection of Cervical
Sup. Mediastinal Esophagus
Esophagectomy
Prepared Gastric Tube Pulled up
Cervical Esophago-gastric Anastomoses
Secure Haemostasis
Place Chest Drain (if needed)

34. Transhiatal Esophagectomy

35. Mobilization of Stomach

36. Blunt Dissection of Thoracic Esophagus
Through Enlarged Hiatus

37. Preparation of Gastric Tube

38. Cervical Esophago Gastric Anastomosis

39. TRANSTHORACIC ESOPHAGECTOMY
(Ivor-Lewis Procedure)
Standard resection through right posterolateral
thoracotomy laparotomy
Good visualization for resection and lymph node
dissection
Requires repositioning the patient
Requires thoracotomy Thoracic anastomosis
More pulmonary complications

41. Three hole Esophagectomy
(McKeown Esophagectomy)
Three holes - Laparotomy, Right Posterolateral
Thoracotomy and Cervical resection.
Cervical anastomosis
Lengthy procedure
Pulmonary complications

42. Left Thoracotomy Approach
Suitable for tumors around GE junction.
Incomplete oesophageal resection
View hampered by arch of aorta and descending
aorta
Thoracic anastomosis
Prone to pulmonary complications.

44. Colonic Reconstruction

45. Jejunal Reconstruction

46. Minimal Invasive Surgery
It involves THORACOSCOPY and
LAPAROSCOPY.
Right sided THORACOSCOPY (No need of CO2
Insuffalation).
Disadvantage: 1.Long anaesthesia
2.Inadequate L.N. dissection
3.High learning curve.

49. Complications
Pulmonary EmpyemaSepsis
Anastomotic Leak.
Conduit Necrosis
Anastomotic Stricture.
Gastro-esophageal reflux.
Colonic dysmotility.
Recurrence

50. Radiotherapy
As primary therapy:
No long term benefit.
Initial relief of dysphagia with median duration 3-6 months.
5 year survival 4 – 14 %.
As adjuvant therapy:
Decrease the loco-regional recurrence rate.
Prevents tracheo-bronchial recurrence in patients with mediastinal
disease after palliative resection.
Adjuvant chemo-radiotherapy:

51. Palliative approach
Aims of therapy:
To reestablish swallowing.
To stabilize body weight.
Laser therapy:
Improve dysphagia by necrosis of tumour.
Nd-YAG laser is commonly used.
Photodynamic therapy:
Dihematoporphyrin ether followed by argon laser.

52. Contd….
Intubation.
Provides long lasting palliation after single procedure.
Beneficial in
infiltrating stenotic or long tumour.
obstruction is due to external compression.
Sealing of TEF.
Tube Types : 1. Atkinson
2. Celestin
3. Souttar
4. Procter Livingstone
5. Expandable Metal Stent
Electro – cauterisation.

53. Carcinoma of Esophagus
Laser Vaporisation

54. Stenting For Carcinoma of
Esophagus

55. Prognosis
5 – year survival
Stage Thoracotomy/
Transhiatal
3 – Field L.N.
Dissection.
Stage I 50% 88%
Stage II 38% 84%
Stage III 10% 54%
Stage IV - 25%