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  2. 2. Anatomy of Esophagus 23 to 25 cm Begins at the level of C6 (cricopharynx) Pierces the diaphragm atT10. It is divided into 3 parts: • Cervical- Neck • Thoracic- Posterior mediastinum • Abdominal- Sub diaphragmatic
  3. 3. Anatomy of Esophagus The esophagus has 4 anatomic constrictions. The first is at the junction with the pharynx (pharyngeoesophageal junction). The second is at the crossing with the aortic arch The third is at the crossing of left main bronchus. The fourth is at the junction with the stomach.
  4. 4. Anatomy of Esophagus Histology- Mucosa: nonkeratinized stratified squamous epithelium Submucosa: esophageal glands and papillae Muscularis propia: striated muscle on the upper third, smooth and striated muscles in the middle third, smooth muscle in the lower third Adventitia: fibroareolar adventitia Upper third Middle third Lower third Artery supply Inf. Thyroid artery thoracic aorta Left gastric artery Venous drainage Inf. thyroid vein Azygos vein Left gastric vein(portal vein) Lymphatic drainage Deep cervical nodes Sup.& inf. mediastinal nodes Celiac lymph nodes Nerve supply The sympathetic fibers from the sympathetic trunks. The parasympathetic supply comes form the vagus nerves.
  5. 5. Globocan 2020 Esophageal cancer is the Eight most common cancer in the world. It is the 7th most common cancer in men and the 13th most common cancer in women. There were more than 600,000 new cases of oesophageal cancer in 2020 It is also the sixth leading cause of death from cancer worldwide. More than 80% of cases and deaths from the cancer occur in developing and less developed countries About 90% of the esophageal carcinoma in the residents of Asia, Africa, and Eastern European countries is SCC overall 5 years survival rate- 20%
  6. 6. Globocan 2022 INDIA
  7. 7. Types of Carcinoma Esophagus (ICD-C 15) 1.According to Site-upper Esophagus-20 %/ middle- most common 50 %/ Lower 30-40% 2. According to histopathology- SCC/Adenocarcinoma/Neuroendocrine tumor/Lymphoma/sarcoma Distant metastasis- Liver was the most common metastatic site in the patients of esophageal cancer and followed by lung, bone and brain. Esophageal cancer is a disease of advanced age, peak in the seventh and eighth decades of life. Stage 5-Year Relative Survival Rate Localized 46% Regional 26% Distant 5% All stages combined 20%
  8. 8. Risk factors for Carcinoma Esophagus (C 15) 1. Smoking 2. Alcohol 3. Tobacco chewing 4. History of Mediastinal radiation
  9. 9. Diagnosis of Carcinoma Esophagus (C 15) Clinical symptoms- dysphagia, pain, weight loss, hoarseness, dyspnea, cough Physical Sign- supraclavicular or cervical LAP, SVC syndrome, Tests 1. Upper GI endoscopy 2. IV/oral contrast study fluoroscopy 3. Biopsy 4. CECT 5. PETCT 6. Endoscopic USG (EUS) 7. Bronchoscopy
  10. 10. TNM Staging 8th edition American Joint Committee on Cancer (AJCC) Cancer Staging
  11. 11. Treatment for carcinoma Esophagus 1. Recommended treatment is primarily decided by stage, tumor location, and patients’ medical fitness. 2. T1-2, N0 superficial esophageal cancer - surgery without induction treatment. 3. T3-4a tumors or nodal disease - induction chemoradiation followed by surgical resection is the optimal treatment. 4. T4b (unresectable) tumors - Definitive chemoradiation is the preferred treatment for patients with and occasionally can facilitate surgical resection in selected cases. 5. For patients with stage I-III disease who receive surgical treatment, 5-year survival is 28%, compared to 10% for those treated medically
  12. 12. Surgery for Carcinoma Esophagus 1.Transhiatal approach 2.Ivor Lewis esophagectomy 3.TTE (The McKeown (or three-incision) esophagectomy 3.MIE-VATS assisted 4.Robot-assisted minimal invasie esophagectomy or (RAMIE)
  13. 13. Transhiatal Esophagectomy A surgeon's hand is best when it is a glove size seven or smaller, as the larger hands can compromise cardiac diastole.
  14. 14. Ivor Lewis Esophagectomy Drawings illustrate transthoracic esophagectomy with a laparotomy and a right thoracotomy (Ivor Lewis procedure). In A, an upper abdominal incision (arrowhead) and a posterolateral thoracotomy (arrow) are made. In B, the esophagus and its adjacent structures are dissected en bloc. Lymph node dissection is also performed. Arrows indicate resection lines. In C and D, an anastomosis is created between the remaining esophagus and the gastric tube. Straight arrow indicates the pyloromyotomy, curved arrow indicates the intrathoracic (C) and cervical (D) anastomosis sites, arrowhead indicates the original cardioesophageal junction.
  15. 15. The McKeown (or three-incision) esophagectomy
  16. 16. Esophagus is a difficult surgery because… 1.Difficult assess 2. Its lack of serosal coat (parietal peritoneum) 3. It surrounded by structures where infection is especially dangerous and rapid Post- op 30-day mortality rate as high as 4%
  17. 17. Risk factors for increase Morbidity & Mortality PAT I E N T R E L AT E D Advance Age Comorbidities-COPD/ CVD/ Hepatic/Renal Obesity Poor Performance status Poor nutritional status, weight loss Smoking/Alcohol Pre-existing abnormal PFT NACT- Cisplatin, 5FU, Paclitaxel S U R G E RY R E L AT E D Duration of OLV Duration of surgery Prescence of hypoxemia Anastomotic dehiscence Hemodynamic Instability Experience of Surgeons
  18. 18. Preoperative screening and optimisation Malnutrition-80% patients 1. Optimization of poor nutritional status- weight loss An overweight patient will have a higher chance of wound infections while an underweight patient has increase mortality. 2. Particular attention should be given to signs and symptoms of esophageal obstruction, GERD, and silent aspiration. Symptoms of obstruction, particularly dysphagia and odynophagia, may lead to reduced oral intake and malnutrition. Symptoms of severe GERD with aspiration may include water brash (hypersalivation in response to reflux), coughing when supine, globus sensation (feeling of lump in throat), laryngitis, and asthma-type symptoms Screening Weight loss 10–15% in the previous 6 months Body mass index 18.5 kg/m2 Serum albumin 3.0 g/l
  19. 19. Nutrition screening &Assessment tools PG-SGA Score NRS-2002 (Nutritional Risk Screening 2002) MUST (The Malnutrition Universal Screening Tool.) Nutrition screening tools European Society for Clinical Nutrition and Metabolism (ESPEN) recommends: the Nutritional Risk Screening 2002 (NRS-2002) for the inpatient setting and Malnutrition Universal Screening Tool (MUST) for the ambulatory setting. Nutritional Supplementation before operation is indicated where patients fail to take 75% of their goal calories and tube feeding is indicated for patients with deficiencies of 50% or more
  20. 20. Role of CPET in Esophagectomy 2019 the following CPET values are proposed as predictive of significant postoperative complications in esophagectomy. AT less than 10.1 mL/kg/min VO2max less than 800 mL/min/m2 Relationship between preoperative CPET variables and post-esophagectomy complications were determined and found that discriminatory ability of CPET for determining high-risk patients was poor in patients undergoing an esophagectomy. CPET may only carry an adjunct role to clinical decision-making.
  21. 21. Morbidity & Mortality predictors POSSUM , P-POSSUM and O-POSSUM (The Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity)
  22. 22. Morbidity & Mortality predictors Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score was developed to provide a predictive index for the development of postoperative pulmonary complications (PPCs). The score has recently been adopted as a standard by the European Society of Anesthesiologists/European Society of Intensive Care Medicine joint task force on perioperative outcome measures. Most esophagectomy patients will fall into the calculated ARISCAT high-risk category.
  23. 23. Postoperative Complications Pulmonary complications (10-25%) Acute lung injury (25%) /ARDS Pneumonia (21%) Respiratory failure (16%) Aspiration Pneumonitis Pneumothorax Pleural effusion Others Post-operative anastomotic leak Supraventricular arrythmias Chylothorax ARF Anastomotic stricture DVT/PE VC Paralysis Wound infection Tracheobronchial tree injury
  24. 24. Postoperative Pulmonary complication Pulmonary damage can be caused by retraction of the collapsed lung during surgery and by reinsufflation at the end of surgery following resection of the tumor. Smokers Fluid overload COPD Inflammatory mediators-Damage to lung lymphatic & Endothelium Silent aspiration OLV GERD RLN Palsy-inadequate cough, aspiration Malnutrition-↓immunity
  25. 25. Preventation of Post-operative Pulmonary complications The risk of developing respiratory complications can be minimized by- 1. Adequate analgesia 2. Reversal of muscular block 3. Normothermia, and haemodynamic stability. 4. Extubation at the end of surgery. 5. Post-op Chest physiotherapy 6. Early mobilization 7. Earlier removal of chest drains
  26. 26. How to decrease ARDS 1.Lung Protective Ventilation Strategy 2.Judicious fluid management 3. Decrease inflammatory markers Pulmonary damage can be caused by retraction of the collapsed lung during surgery and by reinsufflation at the end of surgery following resection of the tumor. In addition, both volutrauma and atelectrauma should be avoided, and adoption of the principles of the ARDS Net trial is advocated. If it occurs, ARDS should prompt consideration of an occult pathology, such as an unrecognized anastomotic leak or sepsis.
  27. 27. high level of positive end-expiratory pressure (12 cm H2O) with recruitment manoeuvres (higher PEEP group) or a low level of pressure (≤2 cm H2O) without recruitment manoeuvres (lower PEEP group). Interpretation A strategy with a high level of positive end-expiratory pressure and recruitment manoeuvres during open abdominal surgery does not protect against postoperative pulmonary complications. An intraoperative protective ventilation strategy should include a low tidal volume and low positive end-expiratory pressure, without recruitment manoeuvres The use of lung protective ventilation strategies during one lung ventilation such as the use of smaller tidal volumes (5 mL/kg), plateau pressures below 35 cmH2O and the application of PEEP has been shown to decrease the inflammatory response and improve oxygenation.
  28. 28. Conventionally, non-invasive ventilation (NIV) has been considered relative contra-indicated in patients with recent esophageal surgery , with concerns that high airway pressure transmitted to the conduit may reduce blood flow or lead to venous engorgement and compromise the anastomosis.. There is a paucity of data to indicate whether NIV is safe. If reintubation is needed, care should be taken to avoid oesophageal intubation as this may directly traumatize the already vulnerable anastomosis.
  29. 29. Perioperative pharmacological therapies to decrease inflammatory marker Perioperative pharmacological therapies to modulate the immune response are not used routinely in the UK, Europe, or North America. However, in Japan and South Korea, this practice is more widespread and briefly discussed here. Methylprednisolone given at the induction of anaesthesia has been shown to reduce pulmonary inflammation. A meta- analysis identified seven trials, all from Japan. There was no difference in death rates, but respiratory complication, sepsis, liver dysfunction, cardiovascular dysfunction, and surgical anastomotic leak were significantly decreased by methylprednisolone pretreatment Pre-treatment with Simvastatin in esophagectomy decrease inflammatory biomarkers as well as pulmonary endothelial injury
  30. 30. Conclusions: High-dose preoperative treatment with oral cholecalciferol reduce changes in postoperative pulmonary vascular permeability index, but not extravascular lung water index. Patients in the salbutamol group had significantly lower lung water, Lower Plateau airway pressure and lower lung injury score at Day 7 than the placebo group VINDALOO TRIAL
  31. 31. Postoperative surgical complications - Anastomotic leak Incidence-10% to 37% Account for as much as 35% of perioperative mortality. Distant anastomosis Avoiding both tissue oedema and excessive vasoconstriction are important. Major leaks present in the first 5 days with severe sepsis Smaller leaks tend to manifest at around 1 week after operation with local neck wound infection, collections, and pleural effusions. Small leaks are managed by keeping the patient nil by mouth, giving high protein enteral feed or total parenteral nutrition, antibiotics, radiologically guided drainage of collection, chest physiotherapy, and performing serial contrast studies. Major leaks require surgical exploration and revision surgery.
  32. 32. Fluid management Specific concern in esophagectomy Prolonged surgery, Third-spacing, Evaporative losses Blood loss Restrictive strategy / Liberal fluid strategy Moreover, restrictive fluid regimens rely on the use of vasopressors to maintain perfusion pressure. For patients undergoing esophagectomy, the perfusion of the gastric conduit depends on the right gastro-epiploic artery and there may be concerns that vasoconstriction can adversely affect flow to the gastric conduit. The ERAS guidelines recommend ‘optimal’ fluid therapy using balanced crystalloids aiming for a weight gain of not more than 2 kg/day Hypotension related to GA & Neuraxial anaesthesia
  33. 33. Increase Postoperative mortality & Postoperative morbidities Heart morbidities ,Pulmonary morbidities Empyema and wound infection , Anastomotic leakage ,Pulmonary embolism ,Recurrent laryngeal nerve palsy, Acute gastric dilatation Cumulative fluid balance from the intraoperative period to postoperative day 2 was identified as an independent risk factor for adverse postoperative outcomes Body mass index, preoperative serum albumin level, use of ACEI or ARB, colloid infusion during surgery, hypertension, peripheral vascular disease, and thoracoscopy were independent risk factors for postoperative AKI (18.3%, out of these 70.3% experienced improved renal function within 48 hours.) There was no association between perioperative crystalloid volumes and AKI; however, exposure to hydroxyethyl starch exhibited a dose-dependent effect on the occurrence of AKI, with each 250-mL aliquot increasing the odds of AKI 1.5-fold
  34. 34. Fluid management SVV is traditionally used during positive pressure ventilation, with a closed chest, and tidal volumes of 8 mL/kg. During thoracotomy the intrathoracic pressure changes that cause a drop in preload, leading to SVV, are not consistent; therefore SVV, as a sole observation, is of limited value. Abdominal phase: optimize SV Thoracic phase: maintain SV (avoiding aggressive fluid loading) The OPTIMISE trial is the largest single study thus far of GDFT in major GI surgery, and patients having upper GI. Although statistical outcome showed no difference in postoperative complications between the 2 groups, there was a trend toward fewer complications in the GDFT intervention group, and there was also no difference in total amount of fluid given between the 2 groups.
  35. 35. Use of Vasopressor & Anastomotic leak!!
  36. 36. Norepinephrine may be a better option than phenylephrine as it more readily preserves cardiac output and produces less splanchnic vasoconstriction and a lesser rise in lactate concentrations than phenylephrine. The notion of completely avoiding vasopressor boluses or infusions is unfounded and likely results in excess fluid administration, a known precipitant of morbidity
  37. 37. Anastomosis site examples are Laser Doppler Flowmetry, Near Infrared Spectroscopy (NIRS), Laser Speckle (Contrast) Imaging (LSI), Fluorescence Imaging (FI), Sidestream Darkfield Microscopy (SDF) and Optical Coherence Tomography (OCT). Although these techniques are very promising most are not yet validated and may be difficult to use and interpret at the bedside.
  38. 38. ICG fluorescent imaging Due to allergic reactions to ICG, it can cause anaphylactic shock in rare cases, as well as cardiovascular reactions, dyspnea, or urticaria . Furthermore, the application of ICG generates significant costs, while it has a half-life of 3–4 min only. In addition, it can lead to interference with the measurement of NIRS (cerebral oximetry & pule oximetry) Potential modalities to ascertain anastomotic integrity - endoscopy, contrast swallow and computed tomography (CT) scan with oral contrast. There is inadequate evidence to justify the routine use of any modality prior to starting oral intake or to establish one modality as superior
  39. 39. Cardiac Arrhythmias Incidence ranges between 12.6- 40%. (3rd MC complication) Mechanisms – Surgical injury to the atria and sympathovagal fibers that innervate SA node is an important mechanism since it may sensitize myocardium to catecholamines and promote arrhythmia. Bilateral vagal section might cause supraventricular tachycardia (SVT). Thoracic dissection or pericardial irritation Postop-Mechanical effects of the gastric tube, sepsis due to anastomotic leak, anaesthesia induced cardiac depression and as hypo- and hypervolemia. Risk factors Old Age, Male gender, Smoking , history of HTN, CHF, PVD and DM ,acid-base imbalance, intraoperative hypoxia and NACT, raised right atrial pressure after OLV AF could function as an early warning sign for other complications in the postoperative course and may thus be of clinical value. The prophylactic use of use of anti-arrhythmic agents is not indicated since it may mask an early warning signal for other complications.
  40. 40. Cardiac Arrhythmias Conclusions: Atrial arrhythmias (AAs) after esophagectomy are associated with higher perioperative mortality, longer hospital LOS, and more incidences of complications. AF generally develops within 3 days after an esophagectomy. Peak incidence on POD2 Conclusions: MIE may reduced the incidence of POAF Moreover, the specific mechanism of MIE providing this possible advantage needs to be determined by larger prospective cohort studies with specific biomarker information from laboratory tests.
  41. 41. Cardiac Arrhythmias Message Prophylactic IV amiodarone is associated with a reduction in AF following esophagectomy, but does not reduce length of hospital stay, and is associated with hypotension, brady- cardia, and QT interval prolongation Prevention Oral beta-blockers should be continued after surgery to avoid withdrawal All patients should receive magnesium (i.v.) perioperatively if the serum magnesium level is low For increased risk, preventive administration of diltiazem or amiodarone may be reasonable AF seldom occurs without complications, so it could function as an early warning sign for anastomotic leaks and may, thus, be of clinical importance. The major adverse effects of β-blockers are bronchospasm in patients with asthma, particularly if the asthma is not well controlled
  42. 42. Antiarrthymatic drugs
  43. 43. Antiarrthymatic drugs
  44. 44. Pain Mechanism Most painful surgical incisions - muscle-sparing approaches Thoracotomy, VATS. Risk factors- Surgery only Good pain relief is important for postoperative adequate respiratory function, compliance with physiotherapy, mobilization, and prevention of complications. TEA is Gold standard TEA has also been associated with decreased incidence of anastomotic leakage, possibly resulting from improved microcirculation in the gastric conduit. Hypotension with TEA can cause problems such as reduction in splanchnic blood flow and, therefore, a decrease in oxygen flux at the gastric anastomosis Chronic pain is also a significant problem after thoracotomy in particular and this can be reduced by good pain relief in the early postoperative period The incidence of chronic pain in VATS appears to be similar to open thoracotomy
  45. 45. Pain Mechanism . This amplified response to pain is called primary sensitization and leads to intensified pain on breathing or coughing after operation. Neuropathic pain -after intercostal nerve injury-results in the paradox of reduced sensory input (from touch, temperature, and pressure) with hypersensitivity (dysaesthesia, allodynia, hyperalgesia, and hyperpathia). Nociceptive Somatic Pain Stimulation- skin incision, rib retraction, muscle splitting, injury to the parietal pleura, and chest drain insertion Somatic Afferents - intercostal nerves to the ipsilateral dorsal horn of the spinal cord (T4–T10). limbic system and somatosensory cortices via the contralateral anterolateral system of the spinal cord. Nociceptive Visceral Pain Stimulations- injury to the bronchi, visceral pleura, and pericardium. Inflammatory mediators, such as prostaglandins, histamine, bradykinin, and potassium, are released. These mediators directly activate nociceptors, enhance their activity, and reduce the pain threshold afferents are conveyed by the phrenic and vagus nerves
  46. 46. Pain Mechanism Referred pain to the ipsilateral shoulder is common after thoracotomy.  This suggests that irritation of the visceral pleura, pericardium or chest drain placed too far into the apex of the hemithorax, referred to the shoulder by the phrenic nerve, is the most likely source of this pain.  As the nerves arise from C3 to C5, TEA is ineffective in blocking this pain.  Studies have demonstrated a reduction in shoulder pain by infiltrating local anaesthetic to block the phrenic nerve at the level of the pericardial fat pad, or alternatively by interscalene block
  47. 47. Systematic review by the Procedure Specific Postoperative Pain Management working group PROSPECT recommend that Ist line of Analgesia-Either TEA with local anaesthetics and an opioid or continuous PVA with local anaesthetics combined with parenteral paracetamol and an NSAID should be used as first-line analgesia for thoracotomy. IInd line of Analgesia-Where these techniques are not possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended, which requires the use of supplementary systemic analgesia.
  48. 48. Chronic post-thoracotomy pain (CPTP) Incidence- 57% of patients at 3 months and 47% at 6 months. This incidence has not improved since the 1990s despite improvements in perioperative care. Pain Character- burning, numbness, or a cutting sensation along the thoracotomy scar. Frequency- Constant or Intermittent Stimulating factors- may be evoked by non-painful stimuli such as changes in temperature or donning clothing. Management- Ideally begin with a review of any modifiable risk factors. TEA decrease its incidence. Exclude other D/D such as malignancy recurrence or the effects of radiotherapy and chemotherapy. A multidisciplinary personalized plan - pharmacological agents, and nerve blocks Agents used include NSAIDs, amitriptyline, gabapentin, opioids, and ketamine. Nonpharmacological treatments used have shown varying success and include behavioural therapies, transcutaneous electrical nerve stimulation, cryoanalgesia, radiofrequency ablation, and spinal cord stimulation The underlying goal of all these agents is to reduce the peripheral and central sensitization that has
  49. 49. Minimally Invasive Esophagectomy A single randomized controlled trial found that MIE reduced blood loss, respiratory complications, and length of stay, and provided a better quality of life at 6 weeks without any difference in node harvest. The anesthetic challenges of MIE include prolonged surgery, often in the prone position, the subsequent increased difficulties of lung isolation and OLV in the prone position, and complications relating to extraperitoneal CO2 (pneumothorax, pneumomediastinum, and surgical emphysema)
  50. 50. Regional analgesic techniques such as paravertebral block and erector spinae plane block are recommended. Serratus anterior plane block can be used as a second choice. Systemic analgesia should include paracetamol and non-steroidal anti-inflammatory drugs or cyclo- oxygenase-2-specific inhibitors administered pre- operatively or intra-operatively and continued postoperatively. Intra-operative administration of intravenous dexmedetomidine is recommended when basic analgesics cannot be given. Opioids should be used as rescue analgesics postoperatively. Thoracic epidural analgesia is not recommended for postoperative analgesia.
  51. 51. The grade of the recommendation was also assessed at three levels of quality: strong, moderate or weak. Strong recommendations are made when the desirable effects of an intervention clearly outweigh the undesirable effects, whereas moderate or weak recommendations result, either because of low quality of evidence or because evidence suggests that desirable and undesirable effects are closely balanced
  52. 52. ERAS Prehabilitation Less than 4 weeks of prehabilitation is unlikely to influence outcomes.
  53. 53. Timing of surgery following neoadjuvant therapy The recommended interval was 3-4 weeks after the last day of chemotherapy. Recent meta-analysis reported that a longer interval to surgery (more than the standard 7–8 weeks) did not increase the pCR rate and was considered to lead to worse long-term outcomes.
  54. 54. Palliative concern Approximately 50% of patients have evidence of distant metastatic disease at the time of diagnosis . Best supportive care is often the most appropriate treatment option. Patients’ performance status should determine whether chemotherapy is added to best supportive care. Specific symptoms that often need palliation include dysphagia, pain, and nausea. Palliative procedures- feeding tubes in some select patients. Endoscopic stenting can be used to palliate dysphagia or cases of bleeding from esophageal tumors.
  55. 55. Operative components