Esophagus—Esophageal Cancer
Concept
One of top leading causes of cancer deaths, squamous-cell has traditionally accounted for the majority of esophageal cancers, but the frequency of adenocarcinoma is increas- ing. Risk factors include achalasia, Barrett’s, caustic injuries, diverticula, leukoplakia, Plummer-Vinson syn- drome, smoking and alcohol use.
Way Question May be Asked?
“A 61 y/o male smoker presents to your office with a new onset of dysphagia. On review of symptoms, the patient has lost 15 pounds in the last month and the dysphagia is worse for solids compared to liquids.” Be careful of the adult patient that presents with an esophageal stricture—
must r/o malignancy with both biopsy and brushing of the stricture for cytology.
How to Answer?
Complete H +P (wt. loss, vomiting, palpable mass, risk factors, check for supraclavicular node, enlarged liver)
Laboratory tests (full labs, nutritional status pre-op)
Appropriate Diagnostic Tests
UGI
Endoscopy and biopsy
Bronchoscopy (if CA in upper 2/3 of esophagus to r/o esophagobronchial fistula)
CT scan chest and abdomen (enlarged LN’s- celiac/mediastinal), metastases to liver/lungs) Endoscopic U/S may be used to provide more accu-
rate staging of tumor invasion and regional node status
Barium Enema/Colonoscopy if might use colon as conduit (don’t need angio pre-op)
Be complete, but don’t dwell on these as the examiner is trying to get to more complicated issues like the indications for surgery/palliation, performance of the surgery, and management of complications after surgery.
Can discuss pre-op nutrition with J-tube feeds or TPN, but must be at least 2 weeks in duration pre-op to see any benefit
Contraindications for Resection
Metastatic disease (must FNA to prove metastatic) Enlarged mediastinal/para-tracheal/celiac nodes Fistula to the airway
Non-Surgical Palliation
Metallic stents Laser fulguration Feeding tubes Intraluminal tubes Chemo/XRT
Surgical Treatment
Can describe Ivor-Lewis procedure or Transhiatal pro- cedure
Remember that cervical anastomosis is safer than intrathoracic
Any transhiatal might need to be converted to thoraco- tomy if tumor is fixed to adjacent structures
Can perform anastomosis as running or interrupted, single or double layer—staplers associated with increased risk of stenosis here
If performing thoracotomy, remember pre-op tests (PFTs)
Stomach is best organ to replace esophagus with Always send to pathology to check intra-op margins
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Post-op UGI day 5–7 depending on preference Maintenance of chest tube/J-tube
Key features of Ivor-Lewis:
Abdominal portion first then right posterolateral thoracotomy
Abdominal exploration Create gastric tube
Preserve right gastric and right gastroepiploic Kocher maneuver to allow gastric pull-up Pyloroplasty/pyloromyotomy
Double lumen tube to deflate right lung Anastomosis in left neck
Key features of Transhiatal:
Be prepared to do thoracotomy Blunt mediastinal dissection
Order = abdominal/cervical/mediastinal/anastomotic
Common Curveballs
Cancer presents as a new stricture in an adult
Anastomotic leak—pt may become septic or may be a silent leak only seen on post-op UGI—management will depend on whether it is in the chest or the neck Necrosis of the gastric tube
Saliva will come out of your chest tube (leak as above) Being asked to describe diversion for total disruption of
anastomosis post-op Pt has fever post-op
Being asked how to boost nutritional status pre-op Pt develops a chylothorax post-op
Delayed gastric emptying post-op
Recurrent laryngeal nerve injury during the surgery Management of late anastomotic stricture
Questions regarding neoadjuvant chemo/XRT Pt may have feature suggestive of unresectability Injury to trachea during cervical or thoracic dissection
(usually to membranous portion of trachea and can usually advance ETT so that balloon distal to tear and then perform repair (may need to split upper sternum to accomplish))
Suture line recurrence
Check frozen section of esophageal margin before mak- ing anastomosis
If positive celiac node found during surgery, then what?
(this is unresectable disease)
Strikeouts
Not treating a stricture as a possible malignancy and performing simply an anti-reflux procedure (getting scenario wrong)
Placing G-tube for pre-op nutrition and destroying stomach as potential gastric tube
Mentioning the use of VATS/laparoscopy in perform- ing the surgical resection
Trying to resect someone with obvious evidence of non- resectability
Not performing pyloroplasty/pyloromyotomy with gas- tric pull-up
Not being able to describe the operation
Not knowing non-operative methods of palliation Not being able to manage the possible complications of
your procedure (always a strikeout!)
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