Clinical study on Carcinoma Esophagus in Government Rajaji Hospital, Madurai

Certificate from the DEAN

This i

s to certify that this dissertation entitled “CLINICAL STUDY ON

CARCINOMA ESOPHAGUS

IN GOVERNMENT RAJAJI HOSPITAL,

MADURAI”

is the bonafide work of

Dr.

M.Udayakumar

.,

in partial fulfillment of

university regulations of the Tamil Nadu Dr. M.G.R. Medical University, Chennai,

for

M.S General Suregry Branch I

examination to be held in

April 2015.

Captain

Dr.B. SANTHAKUMAR , M.Sc(F.Sc) , M.D(F.M).,

PGDMLE., Dip.N.B (F.M) .,

THE DEAN

Madurai Medical College and Government Rajaji Hospital,

Madurai.

INCIDENCE, PATHOLOGICAL PATTERN AND MANAGEMENT OF

Certificate from the HOD

This is to certify that this dissertation entitled

“CLINICAL STUDY ON

INCIDENCE, PATHOLOGICAL PATTERN AND MANAGEMENT OF

CARCINOMA

ESOPHAGUS

IN GOVERNMENT RAJAJI HOSPITAL

,

MADURAI”

is the bonafide work of

Dr.

M

.

UDAYAKUMAR

.,

in

partial fulfillment

of university regulations

of the Tamil Nadu Dr. M.G.R. Medical University,

Chennai, for

M.S General Surgery Branch I

examination to be held in

April 2015.

Dr.A.Sankaramahalingam, M.S.

Professor and HOD,

Department Of General Surgery,

Government Rajaji Hospital,

Madurai Medical College,

Madurai.

Certificate from the GUIDE

This is to certify that this dissertation entitled

“CLINICAL STUDY ON

INCIDENCE, PATHOLOGICAL PATTERN AND MANAGEMENT OF

CARCINOMA

ESOPHAGUS

IN GOVERNMENT RAJAJI HOSPITAL,

MADURAI”

is the bonafide work of

Dr.

M.UDAYAKUMAR

.,

in partial fulfillment of

university regulations of the Tamil Nadu Dr. M.G.R. Medical University, Chennai,

for

M.S General Surgery Branch I

examination to be held in

April 2015

Dr.N.Vijayan, M.S

Professor of Surgery ,

Department Of General Surgery,

Government Rajaji Hospital,

Madurai Medical College,

Madurai.

DECLARATION

I ,

DR.

M.UDAYAKUMAR

, solemnly declare that

this

dissertation

“CLINICAL STUDY ON INCIDENCE, PATHOLOGICAL PATTERN AND

MANAGEMENT OF CARCINOMA

ESOPHAGUS

IN GOVERNMENT

RAJAJI HOSPITAL, MADURAI”

is a bonafide record of work done by me at

the Department Of General Surgery, Government Rajaji Hospital , Madurai , under

the guidance of

Dr.N.VIJAYAN, M.S,

Professor , Department of General

Surgery, Madurai Medical college , Madurai.

This dissertation is submitted to The Tamil Nadu Dr. M.G.R Medical

University, Chennai in partial fulfillment of the rules and regulations for the award

of

M.S Degree General Surgery Branch- I

; examination to be held in

April

2015.

Place: Madurai

Date:

Dr.

MUDAYAKUMAR

,

ACKNOWLEDGEMENT

I would like to thank

Captain

Dr.B. SANTHAKUMAR , M.Sc(F.Sc) ,

M.D (F.M)., PGDMLE., Dip.N.B (F.M) .,

Dean Madurai Medical College and

Government Rajaji Hospital, for permitting me to utilize the facilities of Madurai

Medical College and Government Rajaji Hospital facilities for this dissertation.

I wish to express my respect and sincere gratitude to my beloved teacher and

Head of The Department,

Prof. Dr.A.SANKARAMAHALINGAM, M.S.,

Professor of Surgery for his valuable guidance and encouragement during the study

and also throughout my course period.

I would like to express my deep sense of gratitude, respect and thanks to my

beloved Unit Chief and Professor Of Surgery,

Prof. Dr.N.VIJAYAN, M.S.,

for

his valuable suggestions , guidance and support throughout the study and also

throughout my course period .

I am greatly indebted to my beloved Professors ,

Dr. NASHEER AHMED SYED

, M.S., Dr. SELVA CHIDHAMBARAM, M.S., Dr. MARUTHUPANDIAN,

M.S., Dr. LAKSHMI , M.S., Dr. SYED IBRAHIM , M.S., and

Dr. DHAMODHARAN ,M.S.,

for their valuable suggestions throughout the

course of the study.

I am extremely thankful to Assistant Professor of Surgery of my Unit,

Dr.K.SARAVANAN,

M.S.,

Dr.M.MANIKANDAN,

M.S.,

Dr.P.MUNIASAMY, M.S.,

for their valid comments and suggestions.

I sincerely thank the Professor of Surgical Gastroenterology,

Prof.Dr.

S.PADMANABHAN, M.S. M.Ch (SGE)

&

the Professor of Surgical Oncology,

Prof.Dr. S.S.SUNDARAM, M.S. M.Ch (Surgical Oncology)

for their guidance

and suggestions in my dissertation work.

I sincerely thank all the staffs of Department Of General Surgery and Department

Of Surgical Gastroenterology & Surgical Oncology for their timely help rendered

to me, whenever needed.

I extend my thanks to all my friends, batch mates, any senior and junior colleagues

who have stood by me and supported me throughout my study and course period.

Finally, I thank all my patients, who form the backbone of my study, for their

patience and co-operation .I pray god for their well-being and their speedy

recovery.

VIII

L

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T

O

OF

F

A

AB

BB

BR

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EV

VI

IA

AT

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A →→ AAvveerraaggee

AC → Adenocarca iinnoomam

AG → Agricuulturl iists

B

B →→ BBuussiinneessssppeerrssoonn

B. Pneu → Bronchhooppnneumonie aa

C

Caa →→ CCaarrcciinnoommaa

CE → Carrcicnnoommaa Esophagus

D → Depennddente

D

DOOAA →→ DDaatteeooffAAddmmiissssiioonn

F → Femmalea

G

G →→ GGoooodd

HW → Housewe ifei

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M

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S

IX

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NEEEEDDFFOORRSSTTUUDDYY

Bennigni ttumoorrssoofftthe esoopphhagusa area rare anndd arreeuusuas llyl more bothher-e soms eethant

harrmful.m TheT mmoosstt coommmonm tyyppee ofbbenigne ttumoriissaa leiome yyoommawhiw cchh occcuurrssini peoopplel

b

beettwweeeenn 3300 aanndd 6600 yyeeaarrss ooff aaggee.. OOtthheerr ttuummoorrss ccoonnssiisstt ooff ffiibbrroovvaassccuullaarr ppoollyyppss aanndd

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e

essoopphhaaggeeaallttuummoorrss..

Carrcicnnoommaa ooff esophas gguuss is thet ninthh mmoosts coommmon canncec rr inn the wworldd..

N

Nuummeerroouussssttuuddiieesshhaavveeddeemmoonnssttrraatteeddtthhaattiinnddeevveellooppiinnggccoouunnttrriieesscciiggaarreetttteessmmookkiinnggaanndd

alcl oohhooll cconsuumptim oonn are thet mmoosstt imppoorrtantt pprredispose ingi faccttor for esophas gguuss

c

caarrcciinnoommaa..

Barrrrette ’’ssese oopphhagusa issaa conseqquueenncec ooff chroonniiccggaassttrroo esophas ggeeala rrefle eexx disordes rr

w

whhiicchh iiss tthhee mmoosstt iimmppoorrttaanntt rriisskk ffaaccttoorr ffoorr aaddeennooccaarrcciinnoommaa ooff eessoopphhaagguuss.. SSeevveerraall

esophas ggeale mmotiillittyy disorders havvee beenn impli iicattedd iinn the ddeevellooppmment of esophageala

c

caarrcciinnoommaa..

Carrcicnnooggeennici efeffeecttssooff tobaccoc anda allcoholc isi farmmoorree pronouncede forsquams oouuss

c

ceellllccaarrcciinnoommaatthhaannffoorraaddeennooccaarrcciinnoommaa..

Recentc epie ddeemiolm ooggici aall studit ese hhavea found thhaat oobbeessiitty (meeaasuurred ass body masa ss

i

innddeexx)) iiss aannootthheerr ssttrroonngg rriisskk ffaaccttoorr ffoorreessoopphhaaggeeaall ccaarrcciinnoommaa ssqquuaammoouuss cceellll ccaarrcciinnoommaa

XI R

REESSUULLTTSS

A tootat ll of3300ppataiiente sswew rree operraatet ddwiwtht aaggeeggroupr ((4400--8877yyrrss))wwiitht 2200malm ese anndd

1

100 ffeemmaalleess ((rraattiioo 22::11)) ssqquuaammoouuss cceellll ccaa ((7700%%)),, AAddeennooccaarrcciinnoommaa ((3300%%)) ccaarrcciinnoommaa ooff

Loowew rrtthhiirdesophaguse isi moorreecomc mmoonn..((>70%)> of ppaatiieentss beloonnggede tot bbllood groupAA

(

(4466..66%%)) oorr OO ((2266..66%%)).. TToobbaaccccoo SSmmookkiinngg//cchheewwiinngg,, aallccoohhooll ccoonnssuummppttiioonn,, cchhrroonniicc

i

irrrriittaattiioonnaannddpprree--eexxiissttiinnggeessoopphhaaggeeaallccoonnddiittiioonnssaarreessttrroonnggrriisskkffaaccttoorrss..

C

COONNCCLLUUSSIIOONN

Toobbacca oo,,sms ookking/ci hhewe ingi and allcoholc ccoonnssuummpptitoonnaannddpprreee xxiissttingi esophageala

c

coonnddiittiioonnssaarreessttrroonnggrriisskkffaaccttoorrss..DDiisseeaasseesshhoowwsspprreeddoommiinnaanncceettoommaallee,,mmoorreeccoommmmoonniinn

5

5thh&&66tthddeeccaaddeeoofflliiffee..SSqquuaammoouusscceellllccaarrcciinnoommaaiissmmoorreeccoommmmoonntthhaannaaddeennooccaarrcciinnoommaa

Differrente surgis calc aapproachh has no effffecte oonn durationi of hospitaal stsaay, mortaaliitty or

s

suurrvviivvaall..

K

Keeyywwoorrddss

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N

No. Topic

Paaggee Noo..

1

1.. INTRODUCTU IIONO 1

2

2.. AAIIMMOOFFTTHHEESSTTUUDDYY 33

3

3.. HISTOT RRIICCALA ASPA ECTSE 4

4

4.. REVIEV WW OFF LIITERATURET 7

5

5.. SSUURRGGIICCAALLAANNAATTOOMMYY 1144

6

6.. GGEEOOGGRRAAPPHHIICCDDIISSTTRRIIBBUUTTIIOONN 2222

7

7.. ETIOT PATHOP GEG NEN SISS 24

8

8.. TTRRAANNSSHHIIAATTAALLEESSOOPPHHAAGGEECCTTOOMMYY 2288

9

9.. MMEETTHHOODDOOLLOOGGYY 4433

1

100.. RESULTS SS 50

1

111.. DISCCUSSU IIONO 77

1

122.. CCOONNCCLLUUSSIIOONN 8899

1

133.. SUMMAM RRYY 92

1

144.. BIBLIIOGRAO PHYP 94

A

ANNNNEEXXUURREESS

•

• PPrrooffoorrmmaa 110077

•

• MMaastter Charrtt 116

1

155..

XIII

L

LI

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OF

F

T

TA

AB

BL

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ES

S

T

Taabbllee N

Noo.. TTooppiicc PPaaggeeNNooss..

1

1.. Age distsrributii oonnooffppatia entse studiet dd 5500

2

2.. Genderrddisi tributt ioni of patienti ss studiede 5522

3

3.. Occuuppatia oonnooffppaatientse studiet dd 5533

4

4.. DDuurraattiioonnooffddiisseeaasseeiinnmmoonntthhss 5544

5

5.. CClliinniiccaallffeeaattuurreess 5555

6

6.. Habitst 5566

7

7.. Comoorrbbidi conditionst 5577

8

8.. H/o respis rratorya ailmi eents preoperratia vvelye 5588

9

9.. AAnneemmiiaa 5599

1

100.. HHeemmoogglloobbiinn((%%)) 6600

1

111.. AAllbbuummiinn 6611

1

122.. Blooooddggrroouupp 6622

1

XIV

1

144.. DDuurraattiioonnooffhhoossppiittaallssttaayy((ddaayyss)) 6644

1

155.. Surgicala proceduree 6655

1

166.. Compplicl atia oonnss durinnggsurges rryy 6666

1

177.. PPoossttooppeerraattiivveeccoommpplliiccaattiioonnss 6677

1

188.. PPoossttooppeerraattiivveeRRTTaannddCCTT 6688

1

199.. OOuuttccoommee 6699

2

200.. Correlatl ioni ooff cclilnniicac ll vvaariar bbllese wiwtht oouutcomt ee ((PPost--oopp

coommppllicatc ionsi /del/ ayeda coommpplilcatc ioni ss/M/ oorrtalt ity)i 7700

2

211.. Tablea showings peaka ageiinciddencee bbyyvvaarrious authhoorrss 8800

2

222.. MMeeaannAAggeeiinnYYeeaarrss 8800

2

233.. MMaalleettooFFeemmaalleerraattiioo 8811

2

244.. PresentStSuuddyy--AngiA ooggrraphica LeveL ll of Diiseasee 8844

2

255.. Blooooddggrroouupp 8844

2

266.. Comppaarison studiet ss histsooppathola ooggicai ll behavviouri oofftumt oorr 8855

2

277.. CCoommppaarriissoonnssttuuddiieessbbllooooddlloossss 8866

2

XV

L

LI

I

ST

S

T

OF

O

F

F

FI

IG

GU

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ES

S

F

Fiigguurree N

Noo.. TTooppiicc

P

Paaggee

N

Nooss..

1

1.. Surgicala annatoma yyooffese oopphhagusa 1155

2

2.. Arterriali bbloodl suupppplyl of esophagus 1177

3

3.. Venous drainnagea of esophas gguuss 1188

4

4.. LLyymmpphhaattiiccddrraaiinnaaggeeooffeessoopphhaagguuss 1199

5

5.. NNeerrvveeSSuuppppllyyooffEEssoopphhaagguuss 2211

6

6.. Mobilisi atia oonnoofftthe stomacha 4411

7

7.. Preparratia oonnooffggaastrict conduitc 4411

8

8.. Mobilisi atia oonnini thennecke 4422

9

9.. AAnnaassttoommoossiissiinntthheenneecckk 4422

1

100.. BBaarrggrraapphhsshhoowwiinnggaaggeeddiissttrriibbuuttiioonn 5511

1

111.. Pieggrrapha shhoowiwnnggggendere distsrributii oonn 5522

1

XVI

1

133.. Barrggrrapha shhoowiwnnggdduurratia oonnooffddisi ease ee innmmoonnthst 5544

1

144.. Barrggrrapha shhoowiwnnggmodem of preses nntatt iioonn 5555

1

155.. BBaarrggrraapphhsshhoowwiinngghhaabbiittss 5566

1

166.. PPiieeaannddBBaarrggrraapphhsssshhoowwiinnggccoommoorrbbiiddccoonnddiittiioonnss 5577

1

177.. PPiieeggrraapphhsshhoowwiinngghhiissttoorryyooffrreessppiirraattoorryyaaiillmmeennttss 5588

1

188.. Pieggrrapha shhoowiwnngganema iai 5599

1

199.. Barrggrrapha shhoowiwnngghhemogle oobbini (%) 6600

2

200.. BBaarrggrraapphhsshhoowwiinnggsseerruummaallbbuummiinn((%%)) 6611

2

211.. BBaarrggrraapphhsshhoowwiinnggbbllooooddggrroouuppaammoonnggppaattiieennttssssttuuddiieedd 6622

2

222.. PPiieeggrraapphhsshhoowwiinngghhiissttooppaatthhoollooggiiccaalleexxaammiinnaattiioonn((HHPPEE)) 6633

2

233.. Barrggrrapha shhoowiwnnggdduurratia oonnooffhhoospis talt stsaya (days) 6644

2

244.. Pieggrrapha shhoowiwnnggcomplc icai tionst during surgery 6666

2

255.. PPiieeggrraapphhsshhoowwiinnggppoossttooppeerraattiivveeccoommpplliiccaattiioonnss 6677

2

XVII

2

277.. Pieggrrapha shhoowiwnnggoouutcomt ee 6699

2

288.. Ennddooscs ooppici picturec showings superficiac ll malliignannttesophagee aall caancerr 7711

2

299.. EEnnddoossccooppiiccppiiccttuurreesshhoowwiinnggpprroolliiffeerraattiivveeggrroowwtthh 7711

3

300.. EEnnddoossccooppiiccppiiccttuurreesshhoowwiinnggmmaalliiggnnaannttssttrriiccttuurreeooffeessoopphhaagguuss 7722

3

311.. EEnnddoossccooppiiccppiiccttuurreesshhoowwiinnggmmaalliiggnnaannttcciirrccuummffeerreennttiiaalluullcceerr 7722

3

322.. CTffilmi sshowing Camiddlm ee thirrddese oopphhagusa 7733

3

333.. CTffilmi sshowing Calowl ere thirrddese oopphhagusa 7733

3

344.. EEssoopphhooggoo--ggaassttrreeccttoommyyssppeecciimmeenn 7744

3

355.. MMaalliiggnnaannttssttrriiccttuurreeccaauussiinngg8800%%nnaarrrroowwiinnggoofflluummeenn 7744

3

366.. MMaalliiggnnaannttttuummoouurrooffmmiiddddllee--tthhiirrddeessoopphhaagguuss 7755

3

377.. Malignanti tumourt of loowew rr--thirdt of esophas gguuss 7755

3

388.. Histopathologit calc slsidei showiing adennooccarca iinnoomam 7766

3

1

INTRODUCTION

Tumours of the esophagus are among the most challenging problems

confronting the surgeons.1

Benign tumors of the esophagus are rare and are usually more bothersome than

harmful comprising of (0.5-0.8%) all esophageal tumors.2

Esophageal cancer represents one of the most lethal malignancies affecting the

mankind.3 It is the 9th most common carcinoma of all carcinomas.4 Adenocarcinoma of

the esophagus is increasing in incidence at a rate exceeding that of any other neoplasm.5

Once the overt symptoms appears the average survival rate without treatment is

9 months.6

Most of the patients in our setup presents in the late stages. Considering the rate

of blockage of stents and cost of procedure more emphasis in laid on the surgical

procedure which gives long term relief compared to other procedures.

After several studies controversy still exist regarding the operative management

of carcinoma esophagus even in Indian setup.

Surgical therapy remains the mainstay therapy for patients with respectable

2

Palliation is the primary goal for patient with locally advanced cancers and those

with metastasis. Primary goal of palliation is restoration of swallowing, relief of plain and

local control of the disease.8 To achieve this surgical resection gives best results in all

forms of esophageal cancers.2

Transhiatal esophagectomy can be performed with minimal morbidity and is the

desired operation of choice5and it is better tolerated physiologically.4 It also confers the

advantage of a radical approach and incorporates near total esophagectomy and cervical

anastomosis.9,10

There are many studies reported in the literature which have student the

transhiatal esophagectomy and its complications. However, there is necessity to evaluate

he complications more precisely and group them in form of operative postoperative

complications. Also, comparing such type with mode of presentation and other pre

existing systemic illnesses. There is a need for a new study to evaluate the complication

4

HISTORICAL ASPECTS

2500 BC: “Smith Surgical Papyrus” described repair of the “gullet” after

perforation (no indication malignancy was involved)

AD 0-1: Chinese described esophageal dysphagia from carcinoma.

Circa 2nd Century: Galen described fleshy growths causing obstruction of the gullet.

1849: Long described first use of sulfur either as an anesthetic.

1868: Kussmaul is the first to pass a lighted tube through the entire

esophagus into the stomach.11

1869: Trendelenburg employs the endotracheal route for administration

of anesthesia.12

1871: Billroth successfully resected and reanastomosed the cervical

esophagus in dogs.13

1897: Czerny is the first to successfully resected the cervical esophagus

for carcinoma in humans.14,15

1989: Roentgen published his early investigations on the use of “x-rays”.

1898: Rehn attempted resections of an esophageal carcinoma via right

5

1901: Dobromysslow successfully performed the first intrathoracic

resection and reanastomosis of the esophagus in dogs.

1905: Beck described formations of the gastric tube from the greater

curvature of the stomach, based on the gastroepiploic artery.

1907: Wendell described transpleural resection of an esophageal

carcinoma of the lower esophagus with lateral

esophagogastrostomy in a lumen (patient dies the following day).

1908: Volecker successfully resected a carcinoma of the gastresophageal

junction with primary esophagogastrostomy via laparotomy.

1913: Zaaijer successfully resected a carcinoma of the cardia via an

abdominothoracic approach.16

1913: Denk described the “blunt” or “blind” esophagectomy.17

1913: Turner described the thoracic abdominal approach for blindly

mobilizing the resecting the thoracic esophagus.18

1933: Oshawa resected the thoracic esophagus for carcinoma with

immediate esophagogastrotomy (8 of 18 patients survive).19

1938: Admas is the first surgeon in the United States to perform

transthoracic esophageal resection with immediate

6

1946: Ivor Lewis introduced esophagectomy and esophagogastrostomy

through a right thoracotomy.20

1947: Sweet completed 212 resections for esophageal carcinoma

(17% operative mortality and 8%, 5- year survival).

1963: Logan described 853 resections for esophageal carcinoma

(29% operative mortality).

1978: Orringer and Sloan revived the technical of Gray Turner’s

“esophagectomy without thoractomy”.21,22

1984: Leichman et al at Wayne State University combine 3,000 cGy with

two cycles of 5-FU and cisplatin preoperatively in 21 patients with

squamous cell carcinoma of the esophagus (37% pathologic

complete response; operative mortality 27%).23

1997: Multiple phase III randomized trials fail to show significant

7

REVIEW OF LITERATURE

Esophageal cancer represents the third most common gastrointestinal malignancy

and ranks among the ten most common cancers worldwide.24 U.S. mortality data from

1990-1994 have revealed a steady increase in age adjusted mortality in males as well as

females subjects, due to this malignancy.25

The combined incidence of adenocarcinoma of the esophagus and cardia in

currently estimated at 5.8 per 1,00,000 ranking this tumor among top 15 cancer of white

men in United States.26

In India squamous cell carcinoma is more common and accounts for nearly 75%

of cases. The incidence of esophageal cancer in women is much lower.27,28

Through cultural as well as dietary practices contribute to esophageal cancers,

tobacco and ethanol are believed to be primary risk factors.25,29,30,31

A five to ten fold increase in esophagus squamous cell cancers has been noted

smokers relative to non-smokers and risk of esophageal carcinoma correlates with extent

of tobacco exposure.29,32,33

A multicentric study by Gammon et al as well as additional clinical studies have

indicated that the risk of esophageal cancer is approximately two fold higher in smokers

8

Alcohol abuse has been associated with increased risk of esophageal cancers and

the risk increases with the amount of alcohol consumed.35,36

Vaughan TL and Brown LM demonstrated in two different studies that obesity

may be related to risk of esophageal cancer, particularly adenocarcinoma.37,38

Esophageal squamous cell carcinomas have been associated with nutritional

deficiencies; a low intake of fruits and vegetable may influence the esophageal cancer

risk two fold.25,39,40 Deficiencies in carotene, vit, E, and selenium may also increase the

risk of squamous cell carcinoma in underdeveloped areas.

Dietary practices including drinking hot beverages or ingestion of fermented

vegetables may contribute to increased cancer risk.41,42

Esophageal cancer should be suspected in any patient complaining of dysplasia

and weight loss. A through history should be ascertained focusing on preexisting

conditions as well as tobacco and ethanol abuse which are known to be associated with

cancer risk.

The most common symptom of esophageal carcinoma at the time of presentation

is dysphagia3 palliation is the primary goal for patient with advanced local cancers and

9

Dysphagia is the most common symptom at the time of presentation.43 This

unfortunately is a late sign because the esophageal wall is easily distensible due to lack of

serosa.44 Dysphagia leads to various problems like weight loss, malnutrition and

aspiration pneumonia.45 Anorexia malnutrition, loss of weight cardiovascular and

pulmonary problems will have direct impact on morbidity and long term survival.46,47

Age is also an important prognostic factor as patients over age 70 undergoing

esophagectomy have a postoperative morality of 13%.48

Surgery represents the best chance for cure and best palliation for dysphagia and

local control of the disease.8 Surgical resection gives the best results for all forms of

esophageal cancers.4

The incidence of esophageal stricture is very less in surgery when compared to

radiotherapy.7,49

Most surgeons favour transhiatal resection of esophagus which involves posterior

mediastinal blunt dissection without throracotomy.7,50

Transhiatal esophagectomy can be performed with minimal morbidity and is the

desired operation of choice and its is better tolerated physiologically.4 It also confers the

advantage of radical approach under direction vision and incorporate near total

10

The main goals of this procedure are to resolve dysphagia, to achieve a operative

mortality of less than 10%, to prevent the complications and morbidity (e.g. Infection,

Stricture, reflux and aspiration).8,50

This procedure is preferred in patients of respiratory functions impairment who

are not fit for thoracotomy.7 Regardless of level of tumor the maximum vertical surgical

margin possible is obtained minimizing suture line tumor recurrence. Postoperative

deaths from mediastinitis and sepsis resulting from anastomotic disruption is vertically

eliminated also clinically significant gastresophageal reflux seldom occur.9

A study by Randini-Martini et al showed no apparent difference in postoperative

morbidity in Ivor-Lewis when compared with transhiatal esophagectomy and

Ivor-Lewis procedure had more mortality rate.51

Morbidity in form of blood loss, operating time and fewer days in ICU is very less

despite being performed in older patients.52

Hand sewn anastomosis (oesophago-gastric) are better than the stapled ones in

esophagectomy as demonstrated by Laterza et al.53

The choice of the operation for carcinoma esophagus depends upon many factors

viz., location of tumor, preference of surgeon, body habits, prior operation, condition of

11

Most of the evidence accumulated from random studies suggests that the use of

various modalities of induction therapy provide little or no advantage over primary

surgical resection alone.56

Orringer et al57 reported on 800 patients with cancer of the intrathoracic

esophagus and cardia treated with transhiatal esophagectomy, adenocarcinoma was

present in 69% of cases, where as 28% had epidermoid cancer. Hospital mortality was

4.5%, and morbidity was 27%. Major complication including anastomotic leak (13%),

recurrent laryngeal nerve injury, (7%) wound infection (3%), pulmonary complications

(2%), bleeding (1%) and chylothorax (1%). More than 90% of the patients were

discharged within 21 days of hospitalization. There was an overall statistically significant

survival with adenocarcinoma (24%, v/s 17%).

The study by the University of Michigan group represents the largest experience

with transhiatal resection for carcinoma and survival rate and morbidity were quite

consistent with those reported by other surgeons who practice a similar approach.57,58

Gelfand et al59 reported on 160 patients who underwent transhiatal

esophagectomy, the operative mortality and 5 year survival rates were 2% and 21%

respectively.

Gertsch and Colleagues60 described their experiences with 100 patients, hospital

12

Vigneshwaran et al61 reported on 131 patients who underwent transhiatal

esophagectomy with 2% operative mortality.

Parker SL, Tong et al have demonstrated pulmonary complications are most

common problems encountered in esophagectomy patients. Pneumonia being the

commonest smoking cessation preoperatively, adequate pain control with aggressive

physiotherapy and early ambulation are cornerstones of preventive therapy.

Gastric advancement is without doubt the best esophageal replacement when

esophagectomy in performed for palliation of cancer. The extent of operative dissection

and the resultant physiologic insult are less when preparing the stomach for advancement

compared with colon.

The hospital recovery and time to return of unrestricted alimentation are also

shorter in patients undergoing gastric pull up.62

There was a general belief earlier that a vagally denervated stomach acts like a

denervated tube63,64 and the emptying depends on the gravity65 but recent scintigraphic

studies ambulatory gastric manometry and video fluoroscope have shown that its motility

remains unchanged and the transposed stomach tube acts as a “dynamic conduit”.

Erythromycin is known to enhance the early postoperative contractivity of

13

Bardini et al have reported anastomotic leak of around 12% regardless of method

of suturing. Conduit necrosis is due to ischemia. Anastomotic stricture required dilatation

in upto 4% of patients.

Advances in perioperative care including anaesthetic techniques and nutrition

have enabled mortality rates for resection of esophageal cancer to fall to between 5% to

14

SURGICAL ANATOMY

It’s a hollow muscular tube extending from the pharynx to the stomach i.e. from

C6-T11. The length is approximately 25 cm.

It commences in the midline, slightly deviates to left upto the root of the neck,

returns to the midline at the level T4-T5, at T7 deviates again to the left and pierces the

diaphragm at T10.

1. Cervical constriction: 15 cms from incisor teeth at the level of cricopharyngeus.

This is the narrowest part in the GIT.

2. Aortic arch: 22.5 cms from incisor teeth.

3. Left main bronchus: 27 cms from incisor teeth.

4. Diaphragm: 40 cms from incisor teeth.

Anatomical divisions

1. Pharyngesophageal

2. Cervical

3. Thoracic

15

Fig. 1: Surgical anatomy of esophagus

Pharyngesophageal: It extends from inferior pharyngeal constrictor to upper

esophageal sphincter.

Killian’s dehiscence: It is a potential point of weakness in this segment.

™ Site pharyngesophageal / Zenker’s diverticulum

16

Cervical Esophagus: Extends up to the beginning of T1 measuring 5-6 cms in

length. Surgically, more approachable through the left neck incision, as it tends to course

more towards left of trachea.

Thoracic esophagus: Passes through the superior and posterior mediastinum.

Below the tracheal bifurcation esophagus curves to the right and lies adjacent to the right

pleural cavity. Therefore perforation leads to right pleural cavity. Therefore, perforation

leads to right pleural effusion. Below level of T7, esophagus curves towards that left. So

perforation of the lower third leads to left pleural effusion.

Abdominal esophagus: Measures 1-2-5 cms in length. IT passes through

diaphragmatic hiatus along with vagus nerve and branches of left gastric artery. It is

covered with peritoneum on the anterior and lateral surface. It takes a sharp turn to the

left on entering the abdomen.

Esophagus is divided into 4 principle regions according to American Joint

Committee for Cancer (AJCC) staging:

• Cervical esophagus

• Upper thoracic

• Middle thoracic

17

Most surgeons divide the esophagus into ‘thirds” as follows”:

• Upper third: Cricopharynx to superior portion of aortic arch.

• Middle third: Aortic arch to inferior pulmonary vein.

• Lower third: Inferior pulmonary vein to gastroesophageal junction.

BLOOD SUPPLY

Cervical esophagus: By superior and inferior thyroid artery.

Thoracic esophagus: Mainly supplied by 4-6 aortic esophageal branches.

Lower esophagus: By esophageal branches of left gastric and left inferior phrenic

artery.

18 VENOUS DRAINAGE

Cervical esophagus: Mainly to inferior thyroid vein.

Thoracic esophagus: Left side – left hemiazygos.

Right side – azygos

Abdominal: Left gastric vein which empties into portal vein.

19 LYMPHATIC DRAINAGE

There are 2 lymphatic plexuses in the:

1. Mucosa

2. Mucosal layer

Flow of lymphatics

1. Upper 2/3- upwards

2. Lower 1/3- downwards

Lymph nodes

There are 3 parallel inter connected chains:

1. Paraesophageal

2. Periesophageal

20

Fig. 4: Lymphatic drainage of esophagus

NERVE SUPPLY

1. Cervical esophagus

• Sympathetic- fibres from superior and inferior cervical sympathetic

ganglia.

• Parasympathetic- recurrent laryngeal nerve.

2. Thoracic esophagus

• Sympathetic – upper thoracic and splanchnic nerves

• Parasympathetic – vagus.

3. Abdominal esophagus

• Sympathetic-celiac ganglia

• Parasympathetic–vagus.

The recurrent laryngeal nerve, also supplies cricopharynx, so if there is weakness

of the recurrent laryngeal nerve. Patients tend to aspirate while swallowing.

In addition, Meissners and Auerbach plexus provide an intrinsic autonomic

nervous system within esophageal wall.

21

2. Auerbach plexus-connective tissue between longitudinal and circular

layers.

24

ETIOPATHOGENESIS

Any study of cancer cannot be done without detailed study of causative factors.

The causative factors can be obtained from a detailed study of diet habits, environmental

agents, infectious agents and other factors. The etiologic factors play a very important

role in the pathogenesis of upper gastrointestinal tract cancer.

[1] TOBACCO SMOKING AND ALCOHOL

Ernest Wydner and colleagues carried out several studies since 1957 and have

shown that the extensive use of alcohol significantly increases the risk of esophageal

carcinoma in tobacco users/although alcohol itself does not seem to increase the risk of

this cancer.74

But later on Pottern and Colleagues identified tobacco and alcohol as important

independent risk factors for esophageal cancer and also established that apart from being

independent risk factors, they also exert and synergistic action by potentiating each

other.75 The risk is said to increase with increasing number of cigarettes and duration of

smoking habit.76

Ribeiro et al in his Study said that the risk of esophageal carcinoma varied with

the type of alcohol consumed suggesting that the risk spirits is usually more than twice

than from beer and the risk from wine being intermediate between that for beer and

25

Similar studies carried out in South India by Chitra et al identified Alcoholism,

smoking, and chewing of tobacco as important predisposing for esophageal cancer.78

Studies carried out by Devisor et al indicate that cigarette smokers have 2 to 3 times

increased risk of esophageal and proximal gastric center.79

BETELNUT AND BETEL LEAF

Observatory regarding the association of esophageal cancer with betel nut claims

were made as early as the 1970s by Stephne et al.80 The chewing of betel nut and betel

leaf with or without tobacco is or common practice in certain parts of India. In a study

conducted by Nayar et al at the All India Institute of Medical Sciences, the risk of

developing esophageal carcinoma increased by 3.16 times with the daily habit of clewing

betel leaf and tobacco.28

DIETARY FACTORS

A variety of dietary factors have been implicated in the development of

esophageal cancer, because of their distinct variations in incidence and mortality,

between countries in different socio-economic groups and in migrants and their

offspring’s. The role of diet has been extensively investigated but with in conclusive

results.

Nitrosamines

They have been implicated in the development of esophageal carcinoma.

Khuroo et al in their study, found that the Kashmir Province of India is a high risk area

26

compounds and comprises of Salt tear, dried fish, vegetables (especially brassica

abesecar), red abilities and spice cakes.25

Fruits & Vegetables

Rensburg in his study suggested that or chronic low intake of several

micronutrients, together with an inadequate protein intake, increases the be disposition of

the esophageal epithelium to neoplastic transformation. Diet deficient in vitamins A, C,

E, Niacin, Riboglasin and Zinc have been suggested as risk factors.81

Infectious Agents

The infectious agents may be in the form of viral, bacterial or fungal organisms.

1. Viral Agents: The Viruses that have been implicated is Human Papilloma

virus (HPV) for esophageal cancer. Toh et al found an association between

HPV infection and development of esophageal cancer.82

2. Fungal agents: These have been implicated as etiological agents in

malignancies of esophagus. Bhatior et al in their study isolated fungi in

75% cases of Carcinoma esophagus and the most common species over

candida albicans, species.83

Genetic Factors

The risk of esophageal cancer is found to be more among first degree relatives.

Pour et al in their study found that the risk of developing esophageal cancer among blood

27 Low Socio-economic Status

Several studies, carried out by Enzinger et al proved that low socioeconomic

status is associated with an increase risk of esophageal.

Predisposing lesions

The risk for SCC esophageal Carcinoma include; Achalasia, Caustic injury to

esophagus, tylosis, plumervision syndrome84 and Barrett’s esophagus.

Clinical Course and Prognosis

The clinical course and prognosis of esophageal cancer depends chiefly on the

extent of local strand, lymph node involvement and metastasis.

Esophageal Cancer

The overall prognosis for esophageal carcinoma is very poor with 5 year survival

of around 10% 15%. In esophageal carcinoma, Metastasis to lymph node is very common

because of the rich lymphatic supply of the esophagus, especially to the periesophageal

areas, below the diaphragm and upward to the cervical nodes.

Distant metastasis can occur to lung, liver and adrenal glands.85 Esophageal

cancer is classified according to the 2002 American Joint Committee on Cancer – tumor

node metastasis (TNM) Classification system, which takes into account the

characteristics of the Binary tumour, regional lymph node. Metastasis and digital

metastasis more than 50% of patients have unresectable or metastatic disease at the time

28

TRANSHIATAL ESOPHAGECTOMY

Operative steps

In an otherwise, fit patient subtotal resection of esophagus with esophageal gastric

anastomosis at the neck level should be the sensible, approach of achieving best form of

palliation. For this removes the near total esophagus, reducing the recurrence rate and

restoring their swallowing act. This goal is achieved with admirable success rate by

Transhiatal esophagectomy (THE) as compared to other approach, which is known for

higher morbidity and mortality. If there is an anastomotic leak patients do not end up with

mediastinitis. It is easily managed by drainage and wound care. The patient will be fit for

discharge within 2 weeks after THE. Few cases are also gifted with a bonus of cure.

Transhiatal esophageal resection

It is usually done synchronously by 2 teams of surgeons, one operating per

abdomen and the 2nd surgeon exposing the cervical esophagus.

Procedure

Incision from xiphisternum to 2-3” below the umbilicus. Liver, retrogastric celiac

nodes, spleen, stomach and the entire intestine are seen and palpated. In growth,

29 Steps by the abdominal surgeon

1) The greater curvature of the stomach is freed from its omental attachment by

dividing the omentum outside the gastro epiploic arch. Short gastric vessels are

ligated midway between stomach and the spleen, curved fundic dome is released

by diathermy coagulation applied well clear of the viscera.

2) Posterior wall of stomach is exposed and any adhesions are diathermy divided

under vision.

3) Lesser omentum is divided upto the hiatus, preserving the right gastric artery.

4) With the assistant firmly retracting the pancreas the left gastric vessels are made

taught and double ligated individually. The posterior dissection is carried

proximally upto the hiatus.

5) Duodenum is Kocherised.

6) The hiatus is widened by dividing the crura of the diaphragm keeping in mind the

proximity of IVC and hepatic veins.

7) The index and middle finger are insinuated into the posterior mediastinum, the

growth proper is palpated, limits ascertained and nodes if any palpated. The

esophagus is freed from the vertebrae by gentle finger dissection. Posterior vagus

hooked and divided. Next the esophagus is freed on the right and left sides. The

anterior vagus is hooked and divided, the fingers are carried anteriorly and the

distal esophagus with the growth is mobilized all around. When the major part of

esophagus is mobilized one should carefully palpate the tracheal bifurcation and

the main bronchi and avoid injuring them. At this stage the surgeon’s right hand is

30

During mobilization of thoracic segment of esophagus there is likely to be venous

return impediment, and fall in BP or even arrhythmia. The anaesthetist is to monitor the

BP and Pulse, whenever the systolic BP falls below 60 mm of Hg, the hand is withdraw

and within a few minutes the BP recovers to everyone’s delight. Thus blunt mobilization

of thoracic esophagus is an intermittent procedure, the timing dictated by the anaesthetist.

Also at the time of blunt mobilization the anaesthetist switches onto hand ventilation so

that any inadvertent injury to the tracheobronchial tree is immediately recognized.

Once the abdominal surgeon begins to mobilize the esophagus and gives the go

ahead sign another surgeon being to expose the cervical esophagus.

By the time abdominal surgeon have mobilized upto the tracheal tree the other

surgeon would have mobilized the cervical esophagus and upper thoracic esophagus by

blunt dissection.

9) At this state it is easier for the abdominal surgeon to put his left index of

middle finger from above and feel his right hand fingers from below.

Thus, he is confident of good all around mobilization.

10) Once the esophagus is divided at the neck, the entire esophagus with the

growth is pulled down through the laparotomy wound.

11) The specimen and the stomach are carefully palpated. The stomach is

transected 6 cm distal to the lesion along a line extending from low down

31

12) The stomach is reconstructed into a conduit with staplers. Careful

attention is paid in maintaining the vascularity of the gastric conduit

especially at the angle of sorrow in the lesser curve.

13) The loose thread lying in the posterior mediastinum is stitched to the

stomach and gently pushed up the post mediastinum rather than being

pulled by the silk at the neck end.

14) Feeding jejunostomy (Witzel type) is done as a routine about 12 cm distal

to the D. J. junction.

Stomach

Stomach is the referred viscus to replace esophagus because of:

1. Single anastomosis

2. Easy mobilization

3. Reliable and consistent blood supply

4. Physiological function of receptive relaxation and adaptive

accommodation retained

32 Steps in mobilization of cervical esophagus

1. Incision along the anterior border of left sternomastoid muscle.

2. Greater auricular and accessory nerves are preserved.

3. Middle thyroid vein is ligated and divided.

4. Thyroid gland pushed medially by the assistant fingers rather than by a retractor

and the greater vessels are retracted laterally.

5. Recurrent laryngeal nerve safeguarded.

6. Esophagus mobilized by blunt dissection and tape passed around it.

7. With traction on the tape the distal part is gently mobilized by blunt finger

dissection, keeping in mind the proximity of brachiocephalic vein, left common

carotid artery and aorta.

8. After all round mobilization the esophagus is transfixed with a long thick silk as

low down as possible and divided proximal to the stitch. The distal cut end of the

esophagus is pushed down the mediastinum for the abdominal surgeon to pull out

the specimen per abdomen. After the stomach is pulled down the long silk will

remain in the posterior mediastinum with the free end lying in the neck. This is

used to pull up the reconstructed gastric tube as the case may be.

9. Once the reconstructed gastric tube pulled upto the neck the surgeon ascertains

that the viscera is not rotated and its vascularity is well maintained.

10. An end to side single layered interrupted anastomosis is done 3 0’ PDS. The

33

Complications: Variety of iatrogenic complications of vital structures in close

proximity to the esophagus can occur. Some of them e.g., tracheal tear, aortic tear, may

end up in death on table. Knowledge of anatomy, avoiding aggressive mobilization of

esophagus by keeping fingers close to the esophagus (Ryle’s tube inside the esophagus

helps) and willingness to perform thoracotomy in difficult mobilization will reduce the

rate of complication. Acute myocardial problem may also result in death on table.

PREOPERATIVE

A. Neck level

1. Injury to recurrent laryngeal nerve

During mobilization of cervical esophagus recurrent laryngeal nerve (RLN) may

be injured either by traction or transaction. The result may vary from hoarseness,

coughing, vocal cord paralysis which may lead to aspiration. Bilateral vocal cord palsy

may need re-intubation or tracheostomy. Using finger of the assistant instead of retractor

to retract the thyroid will reduce the incidents of injury to RLN. Since the esophagus lies

a little to the left of midline, left side exposure will reduce the injury to RLN. By keeping

close to the esophagus while passing the tape right nerve will be safe guarded.

2. Injury to blood vessels

34

B. In chest cavity

1. Injury to tracheobronchial tree

Preoperative bronchoscopy is mandatory before esophageal surgery to rule out

any infiltration. Tracheobronchial tree injury occurs more commonly after THE. The

finger dissection should be kept close to esophagus. The volar aspect of the left index

finger passed through the neck guards the trachea, while the right fingers passed through

the hiatus dissects the esophagus from the tracheobronchial (TB) tree. The tear may also

occur due to over insufflation of the cuff. Injury can be recognized by anaesthetist by the

fact of tightness of the bag. Injury will result in inadequate ventilation and drop in

saturation and blood pressure. Instead of over ventilation the tubes should be carefully

advanced into the left bronchus and patient prepared for thoracotomy. Small injuries can

be directly sutured whereas loss of tracheal tissue may be buttressed with pleural flap or a

pericardial flap. Postoperatively ventilation has to be monitored.

2. Tear of azygos vein

After ligation of the left gastric artery and inferior thyroid artery, esophagus

receives its blood supply from small branches from aorta which form sub mucosal plexus.

When these vessels are torn the vessels contract and the bleeding stop. If during

mobilization in THOR, there is a continuous bleeding and steady fall in BP, azygos vein

tear should be suspected and the mediastinum should be packed immediately and the

35

3. Opening of pleural cavity

This invariably occurs in THE and sometimes can result in tension pneumothorax

and if so immediate chest drainage tube should be positioned.

4. Injury to aorta

It is rare injury but it can result in awesome bleeding and could end up in death on

table before thoracotomy could be done.

C. Abdominal cavity

1. Inadequate blood supply to the transposed viscera

When the stomach is used as the conduit the blood supply is maintained by right

gastric and gastroepiploic artery. These vessels should not be subjected to twisting or

extrinsic compression which may result in poor fundal perfusion, venous congestion and

possibly anastomotic break down. The conduit should be transposed into the posterior

mediastinum by a gentle push from the abdomen rather than pull at the neck level.

Volvulus of the transposed stomach can occur. After transposition the stomach lies in the

mediastinum with 180 degree rotation, the greater being rotated anteriorly. If the stomach

rotates through 360 degree than gastric outlet obstruction are even sloughing of the

conduit occur.

Before transposing the stomach venous congestion of the site to the anastomosed

at the neck should be eliminated for this may later interfere with arterial perfusion and

36

In the postoperative period unexplained fever, tachycardia, leucocytosis and

discharge from the neck should alert the physician of breakdown in anastomosis. If

confirmed excision of the sloughed graft and cervical esophagectomy is the choice. Later

substernal colonic transposition may be considered.

2. Injury to spleen, liver and pancreas

Splenic injury could be prevented by avoiding undue traction during greater

curvature mobilization. Small tear from adhesions may be controlled with packing.

Bigger lacerations better dealt with splenectomy. Liver and pancreatic injuries are less

often encountered and easily preventable.

3. Hiatal herniation

Herniation of the abdomen content through the divided hiatus can occur even after

many years. Uncomplicated hernia can remain asymptomatic. When the patient develops

chest pain respiratory distress, fever, leucocytosis, flat but rigid abdomen, obstruction or

strangulation should be suspected. Immediate surgery either by abdominal or thoracic

route should be undertaken.

If at operation hiatus is considered to be very wide it may be sutured to the

37 Postoperative: Early complications

Hoarseness: Due to recurrent laryngeal nerve involvement and usually improves

in 6 weeks time. Intubation trachitis may also cause temporary hoarseness, short course

of steroid will help.

Anastomotic leakage: The incidence of anastomotic leaks various widely and has

been reported upto 53%. Vigneswarn et al classified anastomotic leakage into 3 types.

Type 1: Silent clinically or discovered by the contrast study, usually heal

spontaneously without any stricture formation.

Type 2: Leak with systemic disturbances like fever, pain, leucocytosis, discharges

from the wound. Given time it will heal with wound care and antibiotics. May result in a

stricture.

Type 3: Leak due to ischemia and necrosis at the anastomotic site. May require

exploration and cervical oesophagostomy and later colonic transposition.

Bruce et al in their review article proposed to use the definition as suggested by

38

Definition of leak as adopted from the surgical infection study group87

Leak Definition Treatment

Radiological No clinical signs No change in management

Clinical minor Local inflammation, cervical wound X-ray contained leak (thoracic anastomosis) Fever, WBC, CRP

Drain wound Delay oral intake antibiotics

Clinical major Severe disruption on endoscopy, Sepsis

Change management CT guided drainage (Reintervention)

Conduct necrosis Endoscopic confirmation Reintervention

Absence of serosal coat, tension at the anastomotic site due to imperfect or

inadequate mobilization of the stomach conduit, compression of the conduit at the

substernal level which may affect its vascular integrity, are the local factors contributing

to anastomotic leak. Systemic disease like diabetes, tuberculosis, cirrhosis of the liver,

preoperative irradiation etc., may also contribute to poor healing and anastomotic

leakage.

Leakage in the mediastinum after intrathoracic anastomosis have high morbidity

and mortality. Immediate drainage of the chest cavity should be done along with

appropriate antibiotic. Reoperation to establish the continuity of the GI tract have high

39 Chylothorax

Uncommon complication but can result in nearly 50% mortality if left

unrecognized. Patients who had neoadjuvant RT and patients with the adherent tumour

the thoracic duct is more like to be injured. If there is an excessive discharges of milky

fluid from the ICD chylothorax should be suspected. Estimation of triglyceride and

chylomicron in the drainage will clinch the diagnosis. Excessive drainage for long time

result in nutritional deficiency. Once recognized re-exploration and the ligation of the

duct should be done.

Aspiration: While swallowing liquids in the early stages. This may lead to

fulminate pulmonary complication.

Necrosis of the transposed stomach in the mediastinum: The patient is usually

toxic with respiratory distress, leucocytosis etc. early recognition and re operation is the

only change of survival. At surgery the gastric conduit is dismantled, vascular integrity

ascertained and if the conduit if found to be ischemic that segment is transected and

substernal colonic bypass done.

Pulmonary complications: More common with transthoracic resection.

Complications may range from pneumonia to respiratory failure. Patients with

preoperative uncompromised respiratory diseases are more prone to develop pulmonary

complications. Preoperative radiotherapy, chemotherapy also pre dispose to pulmonary

40

Reflux of gastric contents: This may lead to aspiration and pulmonary

complications. Reflux of gastric contents is more common after intrathoracic anastomosis

compared to cervical anastomosis. The addition of pyloric dilation helps to certain extent

in preventing the reflux. Keeping the Ryle’s tube in the early post operative period and

aspiration also minimizes chances of aspiration.

Late complications

Stricture at anastomotic site: This may present early or even after few months or

years. Early anastomotic leak and wound healing by fibrosis predispose to stricture

formation. The incidences are more common after stapled anastomosis compared to hand

sewn anastomosis. Quite often these patients can be managed with regular dilatation

using a balloon dilator. With delayed occurrence of stricture one should suspect

recurrence at the anastomotic site.

Recurrence of tumour

Anastomotic recurrence

With T4, N1 status with venous permeation, in intrathoracic anastomosis when

less then 10cms of the esophagus is removed and missing skip lesions recurrence is more

common.

41

With adherent tumour and incomplete clearance at esophageal bed predispose to

loco regional recurrence. Such patients are in a poor state of health not suitable for

chemoradiation.

42

Fig. 7: Preparation of gastric conduit

44

Patients were selected from those presenting to the OPD and those referred from

elsewhere.

As mentioned earlier, all fresh patients biopsy proven carcinoma of the esophagus

were included in the study. The following patients were however excluded from the

study:

(a) Inoperable patients,

(b) Patients with history of previous chemotherapy, radiotherapy or

esophageal surgery,

(c) Non-ambulatory patients, and

(d) Patients having malignancy of upper third of esophagus.

1. The cases of carcinoma esophagus which were confirmed by relevant

investigations were subjected to surgery. Operative findings and

postoperative findings were recorded.

2. There were 30 patients of which 20 were male patients and 10 female

patients with age ranging from 40 to 87years.

3. The indication for surgery is mainly palliation to relieve pain and

dysphagia.

4. Depending upon the operability, stage of the disease cases were selected.

5. Preoperative evaluation included history and physical findings. UGI

45

6. The evaluation criteria used were selected on the basis of availability of

resources in our setup, with the aim of using the minimum possible

investigation to achieve the diagnosis and provide optimum treatment.

7. Most of the patients were shifted to postoperative wards except for few

patients who were shifted to ICU immediately after surgery.

8. Laboratory investigation done in each case included:

a. Complete haemogram

b. Coagulation profile

c. Base line renal function serum creatinine, electrolyte, urine routine

and microscopy.

d. Routine chest roentgenograms were done in all the cases.

Diagnostic Investigation done included:

1. Upper GI Endoscopy: The Olympus flexible video endoscope was used

for all patients for diagnostic purposes.

2. Endoscopic biopsy was done for all the patients and the diagnosis was

confirmed by histopathological examination.

3. U/S abdomen was also done in all the patients.

4. C-T abdomen: To know the infiltration into surrounding structures, the

46

5. Pulmonary function tests: In case of patients with pulmonary disease and

in smokers and tobacco chewers to plan anaesthesia and for better post

operative rehabilitation.

Surgical treatment

All the patients underwent elective surgery after the correction of anemia,

improvement of nutritional status, and after thorough preoperative preparation. Vigorous

chest physiotherapy by experts was given in the preoperative and postoperative phases.

Board spectrum antibiotics were given to all patients preoperatively,

47 Operative steps

In an otherwise fit patient subtotal resection of esophagus with esophageal gastric

anastomosis at the neck level should be the sensible approach of achieving best form of

palliation. For this removes the near total esophagus, reducing the recurrence rate and

restoring their swallowing act. This goal is achieved with admirable success rate by

Transhiatal esophageal resection (THE) as compared to other approach, which is known

for higher morbidity and mortality. If there is an anastomotic leak patients do not end up

with mediastinitis. It is easily managed by drainage and wound care. The patient will be

fit for discharge within 2 weeks after THE. Few cases are also gifted with a bonus of

cure.

Compulsorily corrugated drains were kept for all the patients in the neck near the

anastomosis.

Postoperatively patients were given intense monitoring, and all were closely

monitored for development of complications.

Intercostals drain were kept in all the patients in whom pleura was damaged.

Monitoring vital signs of temperature, pulse, respiratory rate, blood pressure,

ECG, monitoring fluid balance, acid base balance, biochemical and hematological

48

Postoperative chest X-ray film to check position of inter costal drainage tubes,

central venous pressure line and to know lung expansion.

Adequate pain control, using narcotic analgesics through either, intravenous,

intramuscular or epidural route and non steroidal anti-inflammatory drugs.

Ventilator care and endotracheal tube care with intermittent suctioning to prevent

aspiration of bronchial secretions.

After checking lung expansion and if the acid base studies and biochemical

parameters are within acceptable limits patients is extubated.

Nasogastric tube is maintained to minimize gastroesophageal reflux and

aspiration and is removed when it is no longer required, usually on the fourth

postoperative day.

Maintenance of intercostal drainage tube in proper position with underwater seal

or negative suctioning (usually the drains are removed after the drainage becomes

minimal)

Neck drain is removed after starting the patient with oral liquids to prevent wound

infection and to detect leak.

Maintaining good oral hygiene to prevent oral infection, which can cause

49

Maintaining good general hygiene and proper positioning to prevent pressure

sores.

Total parenteral nutrition supplementation according to the requirement of the

patient.

Jejunostomy feeding

Usually started after 48 hours after surgery when the bowel starts moving

actively. Feeding is started with clear fluids and gradually changed over to liquid diet.

Commercial formula preparations available can also be used, the usual requirement being

around 2500 kcals per day.

Venous thromboembolism

Prophylaxis with administration of subcutaneous heparin or low molecular weight

heparin, anti-embolism stockings and early ambulation.

Physiotherapy

Physiotherapy with postural drainage, percussion and vibration with breathing

exercises to improve the lung function and encouraging the patient to cough out bronchial

secretions was done by an experts.

• Passive leg exercises to prevent Deep Venous Thrombosis.

• Wound care.

• Patient is monitored in the postoperative intensive care ward for 24 hours

50 Late postoperative care

Implying the importance of maintaining good general hygiene.

Oral feeding is started with soft solids in sitting position dietary intake is

gradually liberalized with emphasis being placed on small frequent feeds as patient will

experience fullness in early stages after operation.

Jejunostomy tube is usually retained in situ till the completion of chemotherapy

for maintaining nutrition as the patient may experience vomiting during this period.

Jejunostomy wound care.

Discharge

The criteria for discharge are:

1. Adequately healed abdominal and neck incisions.

2. Maintenance of normal vital parameters

3. Repeat U.G. scopy after 12 days and if there are no anastomotic

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Fig. 10: Bar graph showing age distribution

The highest incidence was observed in 5th and 6th decade of life, patient aged

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Fig. 21: Bar graph showing blood group among patients studied

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Fig. 28: Endoscopic picture showing superficial malignant esophageal cancer

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Fig. 30: Endoscopic picture showing malignant stricture of esophagus

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Fig. 32: CT film showing Ca middle third esophagus

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Fig. 35: Malignant stricture causing 80% narrowing of lumen

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Fig. 37: Malignant tumour of lower-third of esophagus

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