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Oesophageal Surgery. Mike Poullis. What Is It?. Surgery on the oesophagus Cancer of the oesophagus Ruptured Boerhaaves Syndrome Reflux disease Strictures Achalasia. Anatomy. Normal Oesophagus. Cancer of the Oesophagus. Type and Location of Tumours of Oesophagus. Type Adenocarcinoma

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Oesophageal surgery l.jpg

Oesophageal Surgery

Mike Poullis


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What Is It?

  • Surgery on the oesophagus

  • Cancer of the oesophagus

  • Ruptured Boerhaaves Syndrome

  • Reflux disease

  • Strictures

  • Achalasia





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Type and Location of Tumours of Oesophagus

  • Type

    • Adenocarcinoma

    • Squamous

  • Location

    • Lower third Adenocarcinoma

    • Middle third

    • Upper third Squamous


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Investigating Oesphageal Cancer Patients

  • History

  • Examination

  • Special investigations

    • CXR

    • ECG

    • PFTs

    • CT

    • Oesophgoscopy

      • Endooesphageal ultrasound

      • Barium

      • Manometry

      • 24hr pH




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PFTs

  • FVC and FEV1

  • Major risk of surgery is respiratory complications


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Zones of the oesophagus











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What are the operations?

  • Left thoracophrenotomy

  • Ivor Lewis

  • McKeown

  • Orringer Transhiatal esophagectomy (THE)

  • Transabdominal

  • En Bloc resection

  • Endothoracic endooesophageal pull through

  • Total gastrectomy and Roux-en-Y reconstruction

  • Thorascopic eosphagectomy


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What are the operations at CTC?

  • Left thoracophrenotomy +/- neck anastomosis

  • Ivor Lewis

  • McKeown


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Left thoracophrenotomy +/- neck anastomosis

  • Tumour location

    • Lower third

  • Incision

  • Resect tumour

  • Mobilise

  • Re anastomose ? Neck ? thorax


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Ivor Lewis

  • Tumour location

    • Middle third

  • Incision

    • Abdominal

    • Thoracic

  • Resect tumour

  • Mobilise

  • Re anastomose ? Neck ? thorax




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McKeown

  • Ivor Lewis with a neck anastomosis


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Staging

  • T descriptor

  • Tis. Carcinoma in situ.

  • TI. Tumour does not extend into the muscularis propria.

  • T2. Tumour invades muscularis propria.

  • T3. Tumour extends beyond the muscularis propria

  • T4. Tumour invades adjacent structures.

  • Ndescriptor

  • NO. No regional lymph-node metastasis.

  • NI. Regional lymph-node metastasis.

  • Regional lymph nodes are difficult to define lower thoracic lymph node metastases from a cervical oesophageal tumour are considered distant (M) disease, as are coeliac lymph node metastases from a lower-third oesophageal carcinoma.

  • M descriptor

  • No distant metastases.

  • Distant metastases.

  • For tumours of lower thoracic oesophagus:

    • Mla. Metastasis in coeliac lymph nodes. M lb. Other distant metastasis.

  • For tumours of mid-thoracic oesophagus:

    • Mia. Not applicable. Mib. Nonregional lymph node or other distant metastasis.

  • For tumours of upper thoracic oesophagus:

    • Mia. Metastasis in cervical lymph nodes. Ml b. Other distant metastasis.


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Outcome

T1a Tumor invades lamina propria

T1b Tumor invades submucosa

Lymph node 5-year metastasissurvival rate

T1a 0% 100%

T1b 47% 86% without nodal metastasis

43% with nodal metastasis


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Outcome

  • N1 Regional lymph node metastasis

    • N1a 1-3 nodes involved

    • N1b 4-7 nodes involved

    • N1c >7 nodes involved

      2-year 5-year Median survival survival survival rate rate (months)

      N1a 22% 11% 12

      N1b 18% 0% 9

      N1c 0% 0% 6


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Post Operative Complications

  • Early complications ( days 0 to 5) include

    • Poor urine output and low blood pressure

    • Bleeding

    • Respiratory complications

    • Medical comorbidity

  • Intermediate complications ( days 3 to 10) include

    • The septic patient

    • DVT and PE

    • Medical comorbidity

  • Late complications ( days 5 to 10) include

    • Anastomotic leaks and new onset atrial fibrillation

    • Aspiration

    • Chyle leaks

    • The septic patient

    • DVT and PE

    • Medical comorbidity


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Post Operative Leaks

  • Always think leak to explain anything!


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Ruptured Oesophagus Boerhaaves Syndrome






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Next week23rd NovemberThoracic Surgery ComplicationsLecture Theatre


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