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Esophagus - Anatomy

Surgical anatomy
• Muscular tube 25 cm long
• Extent – cricopharyngeal sphincter to
cardia of the stomach
• 2 cm esophagus lies below the diaphragm
• Three constrictions
– Cricopharyngeal -15cm from incisor
– Aorta – 25 cm from incisor
– Left bronchus – 25 cm from incisor
– Diphragmatic and sphinctric constriction –
40cm from the incisor
Esophagoscopy
• Two types
– Fibre-optic
• Commonly used
• Used under light sedation
• Reduced chances of
perforation
– Rigid (done after barium
swallow)
• Not used commonly
• Needs anaesthesia
• Used for removing foreign
bodies
Esophageal Carcinoma
Introduction
• the seventh leading cause of cancer death worldwide.
• Common in areas of northern Iran, some areas of
southern Russia, and northern China.
• Squamous cell carcinoma is common but recently the
cases of adenocarcinoma are increasing
• Male more than female.
• sixth and seventh decades of life.
(probably no other carcinoma causes greater misery to
the patient due to development of inability to swallow
even fluids)
pathology
• Macroscopically three types
1 An annular stenosing lesion usually
found at the cardia
2. An epitheliomatous ulcer with raised
everted edges
3. A fungating cauliflower like friable mass
Spread of the cancer
• Direct .the main method of spread and
most important to the surgeon. it is both
longitudal and transverse in direction and
erodes the muscular wall
• Lymphatic .
• Bloodstream metastasis to liver are fairly
common and bone secondaries can also
occur
Etiology
• Squamous
– cigarette smoking and chronic alcohol exposure are the most
common etiological factors for squamous cell carcinoma.
– Chronic ingestion of hot liquids or foods
– Vitamin or nutritional deficiencies
– Poor oral hygiene
– Exposure to nitrosamines in the environment or food
– Certain medical conditions (e.g., Plummer-Vinson syndrome)
and caustic injury to the esophagus
– Human papilloma virus infection
• Adenocarcinoma
– GERD is the most common predisposing factor for
adenocarcinoma of the esophagus
– Barrett's esophagus
Clinical features
• Progressive dysphagia initially experienced for solids, but
eventually it progresses to include liquids
• Only 40 % patient report in within 3 months
• feeling that food is sticking on its way down to the stomach
• Weight loss is the second most common symptom
• Pain or discomfort can be felt in the epigastric or retrosternal area.
• Hoarseness caused by invasion of the recurrent laryngeal nerve
• Respiratory symptoms can be caused by aspiration of undigested
food or by direct invasion of the tracheobronchial tree by the tumor.
• the regurgitated material is alkaline mixed with saliva and possibly
streaked with blood
• Pain if it occur is usually a late manifestation (but is not a
contraindication to an exploratory operation)
Diagnosis

• Endoscopic ultrasound - the depth of penetration of the


tumor (T staging) and the presence of enlarged
periesophageal lymph nodes
• Abdominal and chest CTscans - exclude the presence of
metastases (M staging) to the lungs and liver and may be
useful to help determine if adjacent structures have been
invaded
• Exfoliative cytology .in China lavage of the esophagus
and examination of the fluid for malignant cell have lead
to discovery of early carcinoma when radiology and
oesphagoscopy have been negative
• Dysphagia requires dilation again after a month the
diagnosis is usually carcinoma
• Many of these patient have a long
standing nutritional deficiency and
therefore hemoglobin,plasma protein and
blood chemistry must all be checked and
corrected ,if necessary before surgical
treatment
• Principal a gastrostomy should never be carried out for
esophageal carcinoma .
• It is no longer required as preoperative measure to
improvise a patient nutrition because this can be carried
out asby 2-3 mm tube from the nose to the stomach or
by modern regimens for iv feeding
• It should never be carried out only to prongle the life of
the patient who cannot swallow the food because the
subsequent state of the patient when inevitable
inhalation lung complication occur due to inability to
swallow saliva is most distressing
• Curative treatment should be either
resection of the tumor or a radical course
of radiotherapy but only 25 % of all the
patient are suitable.the remainder require
some palliative radiotherapy or palliation
bypass
• A curative resection implies that no visible macroscopic tumor has been left behind.
• A pallitative resection means that recognisable tumor has acutally been left in situ
• Histological confermation of the curative rescection by examining the lateral margin
spread and longitudinal extent must alwas be done.unfortunatly 25% of the patient
present in late stage where no treatment can be done only short term measures to
reduce the suffering
Curative treatment by surgery
• Operative aim is to remove the tumor and to restore
continuity by the interposition of the stomach, jejunum or
colon
• Curative treatment should me attempted providing
• 1. the patient is fit enough on general appearance to
withstand a very major surgical procedure
• 2.there is no evidence of spread to the supraclavicular
glands , tracheobronchial tree or liver
Postcricoid carcinoma
• To optain a good chance of cure the tumor must have not
spread too far laterally but it is also important for the surgeon
to excise at least 10 cm margin longitudinally to minimize the
chance of recurrence at the anastomosis . This implies that it
is difficult to optain such a margin in tumors of the postcricoid
region and the upper one third of the oesophagus .
• So postcricoid carcinoma of the esophagus should be treated
by radiotherapy
• Alternative surgical treatment pharyngolaryngectomy with
gastric transposition, colon transposition and tracheostomy is
major undertaking with major complication
• Esophagoscopy: direct visualization and biopsies of
the tumor
• Barium swallow-
helping detect
strictures and
intraluminal
masses
• Chest CT scan showing invasion of the trachea by esophageal
cancer.
• Esophageal cancer: Staging T3N1
• Bronchoscopy is indicated for cancers of the
middle and upper third of the thoracic
esophagus to help exclude invasion of the
trachea or bronchi.
• Bone scan is indicated in patients with
complaints suggestive of bone metastases.
• Laparoscopy and thoracoscopy have a greater
than 92% accuracy in staging regional nodes.
• A new modality for staging is positron emission
tomography scanning, which can help elucidate
hypermetabolic foci of disease activity
• the left adrenal gland
(thick pink arrow), 2 foci
in the anterolateral right
chest wall (thin orange
arrows), 2 paraspinal foci
in the right mid-lumbar
region (thin purple
arrows), the left upper
lumbar paraspinal region
(curved blue arrow), the
right supraclavicular
region (red arrow head),
and the mid-to-lower
esophagus (thick yellow
arrow).
Differential diagnosis

• Benign tumor- leiomyoma


• Achalasia cardia
• Esophageal Stricture
• Peptic strictures due to reflux
Management

• Medical
• Surgery
• Radiotherapy
Surgery
• Esophagectomy is the treatment of choice
for esophageal cancer.
– Transhiatal esophagectomy
– Transthoracic esophagectomy
– Ivor-Lewis 2 stage and 3 stage surgery
• Contraindications
– metastatic disease,
– tumor invasion of nearby structures
– severe cardiovascular or pulmonary disease.
complication
• fistula of esophageal anastomosis
Radiation Therapy
• Palliative
• neoadjuvant therapy
• adjuvant therapy
• Each treatment lasts a few minutes and treatment is
usually given 5 days per week, for 6 weeks.
• Side effects include the following:
– Dental cavities
– Difficulty swallowing
– Dry, sore mouth and throat
– Fatigue
– Loss of appetite
– Reddening of the skin
– Swelling of the mouth and gums
Chemotherapy
• Chemotherapy is not used as a primary
treatment for esophageal cancer.
• Commonly cisplatin, 5-FU and paclitaxel
based combination is used
• Common side effects include the following:
– Diarrhea
– Fatigue
– Hair loss
– Loss of appetite
– Mouth and lip sores
– Nausea and vomiting
– Skin rash and itching
Stage wise Therapy
• Stage 0: Surgery is the best therapy
• Stage I: surgery.
• Stage II and III:
– surgery
– chemoradiation followed by surgery.
• Stage IV: Palliative therapies
– radiation therapy,
– chemotherapy,
– Bypass- stenting, laser therapy, surgical.
Prognosis

• Advanced disease and metastatic


esophageal cancer have a poor
prognosis.

• The overall 5-year survival rate for


esophageal cancer is 20-25%