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Esophageal Cancer. Approx. 13,000 cases/year in USA Post-esophagectomy overall 5 yr survival = 18% At presentation, 57% patients are Stage 3 , with a 10% post-esophagectomy surv. At presentation, 24% patients are Stage 2 , with a 35% post-esophagectomy surv.

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Esophageal cancer l.jpg
Esophageal Cancer

  • Approx. 13,000 cases/year in USA

  • Post-esophagectomy overall 5 yr survival = 18%

    • At presentation, 57% patients are Stage 3, with a 10% post-esophagectomy surv.

    • At presentation, 24% patients are Stage 2, with a 35% post-esophagectomy surv.

    • At presentation, patients who are Stage 1, have an 80% post-esophagectomy surv.


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Esophageal CA -- pre-op staging

  • TNM staging somewhat overbroad

    • If T1, but tumor is in mucosa only:

      • Lymph node metastases < 10%

    • If T1, but tumor extends into submucosa:

      • Lymph node metastases = approx. 30

  • Distant mets, lymph nodes, wall penetration


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Esophageal CA -- find distant mets

  • Distant mets

    • CT chest and abdomen -- mostly useful in trying to detect distant mets

    • but, CT chest and abdomen -- only 60% accurate in detecting regional lymph node disease

    • but, CT chest and abdomen -- underestimates tumor stage in 40% of patients

    • Addition of PET may improve accuracy


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Esophageal CA -- find distant mets

  • Distant mets

    • Bronchoscopy in proximal and middle third esophageal CA’s

      • eval. for posterior tracheal invasion

        • “slight compression” still resectable

        • “abnormal tracheal mucosa” unresectable


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Esophageal CA -- eval. lymph nodes

  • Lymph node status

    • Thoracoscopic staging can find LNs, but poorly predicts unresectability

    • Laparoscopic staging can change treatment in 30% of distal esophageal Cas

      • Matted celiac nodes

      • Carcinomatosis

      • Small liver lesions


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Esophageal CA -- eval. lymph nodes

  • Lymph node status

    • Laparascopic staging

      • Laparscopic ultrasound of liver not useful


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Esophageal CA -- pre-op staging

  • Wall penetration

    • Endoscopic ultrasound -- incorrect in determining wall depth 15-20% of the time

    • Endoscopic ultrasound -- incorrect in determining nodal status 25 - 30% of the time

    • Endoscopic ultrasound -- less accurate after neoadjuvant therapy


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Esophageal CA -- pre-op staging

  • Wall penetration

    • “High grade dysplasia” = 43% occult adeno CA

    • Tumor limited to submucosa --> 19% LN involvement

      • 3% had more than 4 nodes

      • Nodes limited to peri-esophageal, not spleen or peri-gastric => no need to resect these

    • Invasion of muscularis propria --> 80% LN involvement


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Esophageal CA -- chemoradiation

  • Treatment of choice for Stage 4 (mets)

    • Stent esophageal lesion, chemo and radiation

      • SCC responds to radiation better than Adeno CA


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Esophagectomy -- Types of operations

  • Incision strategies:

    • Ivor-Lewis

      • Laparotomy, thoracotomy

    • Transhiatal

  • Conduit strategies:

    • Gastric pull-up

    • Colonic interposition

    • Jejunal interposition


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Esophagectomy -- Types of operations

  • Anastomosis strategies:

    • Location:

      • Cervical

      • Intrathoracic

        • Anastomotic technique does not affect leak rate

        • Radiation, vascular supply does

  • Post-op feeding strategies:

    • Jejunosotmy feeding tube placed at time of esophagectomy


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Esophagectomy -- Types of operations

  • Anastomosis strategies:

    • Technique:

      • Stapled (EEA)

        • Ease

        • Strictures

      • Sutured

        • single layer vs double layer, running vs interrupted


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Esophagectomy -- Types of operations

  • Anastomosis strategies:

    • Tension issues

      • Tacking sutures not often used in stapled anastomoses

  • Gastric emptying strategies

    • 15% pyloric obstruction rate

    • Pyloroplasty, pyloromyotomy ?

      • +/- Graham patch

  • Vagotomy


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Esophagectomy -- Intra-operative complications

  • Bleeding

    • average < 800 cc for Ivor-Lewis

    • transhiatal esophagectomy bleeding

      • left thoracoabdominal extension vs. left thoractomy

      • Aortic a., bronchial a., azygous v. bleeding --> pack, then upper sternal split

  • Tracheobronchial injury

    • secure airway by advancing ETT, then repair

      • primarily vs. pedicled flap buttress


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Esophagectomy -- Intra-operative complications

  • Recurrent laryngeal nerve injury

    • especially in cervical dissections


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Esophagectomy -- Operation by stage

  • Barrett’s esophagus with High-grade dysplasia or intramucosal adeno-CA

    • No visible tumor on endoscopic U/S

      • but again, U/S may not be accurate in distinguishing mucosal vs. submucosal confinement

    • Vagal sparing esophagectomy, transhiatal esophagectomy

      • If no regional disease detected


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Esophagectomy -- Operation by stage

  • Barrett’s esophagus with High-grade dysplasia or intramucosal adeno-CA

    • No visible tumor on endoscopic U/S

      • but again, U/S may not be accurate in distinguishing mucosal vs. submucosal confinement

    • Investigational: Mucosal ablation (laser, photodynamic), endoscopic mucosal resection


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Tumor confined to submucosa on U/S

Visible tumor on endoscopic U/S

75% have tumor past mucosa into submucosa and beyond when seen on U/S

56% have lymph node metastases (both limited to and extending past submucosa)

Extended transhiatal esophagectomy

Complete lower mediastinal and upper abdominal lymph node resection

since only 19% had LNs if limited to submucosa

not “en bloc” since only 3% had > 4 LNs

Esophagectomy -- Operation by Stage


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Esophagectomy -- Operation by Stage

  • Tumor into or through muscularis propria

    • 75% to 85% LN involvement

    • 45% have > 4 LNs

    • 30 - 40% have distant LNs involved (25% celiac LNs)

    • radical en bloc esophagectomy (DeMeester)

      • 1-5 % local recurrence rate

    • however, most surgeons do not perform radical en bloc resections, relying on adjuvant therapy

      • 35% local recurrence operation alone (i.e. not “en bloc”)


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Esophagectomy -- Operation by Stage

  • Radical en bloc esophagectomy (DeMeester)

    • 1-5 % local recurrence rate

      • Compare 35% local recurrence overall after esophagectomy

    • Five-year survival for Stage 3 is 23 - 50%

      • Compare overall five-year Stage 3 post-esophagectomy survival rate of 10%

  • Cervical lymph node dissection

    • Mid-thoracic tumors and upper third tumors have 45% cervical lymph node mets


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Esophagectomy -- Operation by Stage

  • Cervical lymph node dissection

    • Mid-thoracic tumors and upper third tumors have 45% cervical lymph node mets

    • No survival advantage to cervical LN resection (Nishimaki, 1999)

      • Exception was 1 to 4 LNs (but how can you tell in advance?)

    • Significant additonal morbidity (80%) with additional lymph node (“three-field”) dissection


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Esophagectomy -- Complications

  • Mortality 3 - 5%, Morbidity 15-18%

  • Anastomotic leaks -- 1 - 5%

    • Cervical

      • leak rate 0-12%, post-op day 5-10

      • fever, crepitance, drainage, erythema, leukocytosis

      • requires wide incision and drainage, not repair

      • 1/3 develop stricture --> I&D (not repair)


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Esophagectomy -- Complications

  • Thoracic --> Gastrograffin swallow vs. CT

    • With-hold feeding additional 5-7 days if < 1 cm contained leak

      • Repeat esophagogram

    • Exploration if free leak or > 1 cm contained leak (risk of erosion by mass effect)

    • Pediatric endoscope at exploration time (?)

    • Assess for large disruptions or necrosis of conduit


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Esophagectomy -- Complications

  • Conduit necrosis or large disruptions

    • Resect anastomosis, debride edges

    • End cervical diverting esophagostomy

    • Gastric remnant returned to abdomen

    • Drainage

    • Reconstruction in several months


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Esophagectomy -- Complications

  • Conduit obstruction at diaphragm

    • Two fingers width alongside conduit at diaphragm

    • Resect head of left clavicle, first rib, manubrium in cervical anastomoses as needed

  • Diaphragmatic bowel herniation

    • Prevent by suturing conduit to hiatus with 3 - 4 sutures

    • Vague lower thoracic/upper abd. cramping pains

    • CXR; CT or contrast study if in doubt

    • Repair with hiatal closure and anchoring sutures


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Esophagectomy -- Complications

  • Chylothorax

    • 1 - 3%

    • Ligate intraoperatively when identified

    • Massive (800 cc/day) chest tube output at 5 - 7 days post-op vs. tension chylothorax if no Chest Tube

    • Feed cream -- note change in chest tube character

    • Stop enteral feeds; start TPN

    • Explore promptly and ligate thoracic duct through right thoracotomy, VATS, or prior thoracotomy


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Esophagectomy -- Complications

  • Anastomotic strictures -- 5 - 42%

    • More often if lye, leak, small EEA staplers, suture technique, irradiation

    • Requires dilatation (80% dilatation success)

      • Early after leak

      • Combined with endoscopy

      • Use 46 Fr or larger Maloney dilators, balloons when necessary

      • Repeat until 6 months of stability

      • use extra care if colon, small bowel conduit

    • Chronic (> 12 mo) cervical anastomotic strictures

      • Stricturoplasty / SCM flap (50% failure) / Lat. Dorsi flap / free radial arm flap / pectoralis myocutaneous flap (like ENT flaps)


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Esophagectomy -- Complications

  • Delayed hemorrhage (rare)

    • Consider splenic injury

  • Aspiration pneumonia -- 3%

    • Videoesophagogram before re-feeding 5-7 days

  • Dysphagia

  • Regurgitation

  • Delayed emptying

    • Only 15% develop pyloric obstruction

    • Balloon dilatation, erythromycin, metoclopramide

  • Dumping


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Esophagectomy -- Post-op diet

  • Smaller, more frequent meals

  • Drink liquids after meals to avoid gastric distension

  • Avoid high carbohydrate diets

  • Liberal anti-diarrheal use

    • Dumping symptoms usually resolve in 6 - 12 months


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Esophageal CA -- radiation

  • 20 to 40 Gy over 2 - 4 weeks (1.75 to 3.75 Gy/fx)

  • Squamous cell carcinoma -- more radiosensitive

  • Preoperative radiation versus surgery alone

    • no improved survival in long-term randomized trials

  • Post-op radiation versus surgery alone

    • no improved survival, but higher stricture rate

    • improved local recurrence rates in node negative mid- to upper-third SCCs


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Esophageal CA -- chemo

  • Pre-operative chemo (Cisplatin, 5-FU)

    • Only 19% response

    • No change in survival

    • No change in local recurrence rates or patterns


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Esophageal CA -- chemoradiation

  • Pre-op chemoradiation (cisplatin/5-FU)

    • 40% (histologic) response rate (average)

      • Similar response rates for SCC and AdenoCA

      • Response rate dependent on time to surgery following chemoradiation

      • What is ideal delay to surgery?

        • In rectal CA, 6-8 week gap allows more restorative surgery than does a 2 week gap

        • Allow healing ability to recover

        • Allow clinical tumor shrinkage


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Esophageal CA -- chemoradiation

  • Pre-op chemoradiation (cisplatin/5-FU)

    • Increases surgical M/M by 5-15%

      • With high does rad’n (high dose (3.5 Gy) /fraction (TE fistula)

      • Anastomotic leaks, strictures

      • Toxicities

        • myelotoxicity if Mitomycin C, etoposide, vinblastine added

      • Average results, not controlled by delay to surgery


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Esophageal CA -- chemoradiation

  • Pre-op chemoradiation (cisplatin/5-FU)

    • Non-significant improvements yet seen

      • Urba(2001, AdenoCA only) : 3 year survival 16% --> 30% (P=0.15)

        • Local recurrence 41% --> 19%

      • Clark(2000abstract) : 2 year 35% --> 45% (P=.002)

        • median survival difference 4 months, short F/U

      • Walsh (1996, adenoCA only) : highly controversial: 6% --> 32%

      • Bossett(1997, Stage 1 and 2 SCC only): no difference


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Esophageal CA -- chemoradiation

  • Pre-op chemoradiation (cisplatin/5-FU)

    • Survival differences may be lost by 5 years

    • Benefits not yet substantiated by long-term studies (2002 review)


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Esophageal CA -- chemoradiation alone

  • Chemoradiation instead of surgery

    • Studies show pathologic and clinical response rates comparable to historical esophagectomy survivals in Stage 2 and 3 carcinomas

      • EORTC trial in progress -- 30 Gy with 5 FU/Cisplatin

    • Comparisons are not against “en bloc” resections


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Esophageal CA -- chemoradiation alone

  • Chemoradiation (CRT) instead of surgery

    • 40-60% of CRT alone die with local recurrence/failure

      • Compare 9% with CRT plus surgery

  • Surgical salvage following CRT alone

    • no difference in salvage versus CRT alone


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Esophageal CA -- chemoradiation alone

  • Chemoradiation instead of surgery

    • Current methods to determine complete (clinical) response are inadequate to predict which patients might not require surgery in addition to chemoradiation

      • Endoscopic U/S or MRI -- accuracy inadequate in determining local and regional tumor

      • PET, CT -- can’t detect regional nodes well

      • Histologic response -- not avail. without resection

      • Future: biologic serum markers ?


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