Surgery for Carcinoma Esophagus

Dr L.AnandMS MCh FRCS DNB

Associate Professor

Institute of Surgical Gastroenterology

Madras medical College

Management Options

•SURGERY• Chemoradiation

• Radiation

• Sandwich therapy

• Stents

Still undetermined

Paucity of scientific information

Raging debates

________________________

No consensus

Carcinoma Oesophagus

Surgery is the Mainstay

In Resectable Disease!

Issues:

1. Relief of dysphagia

2. Aim towards zero operative mortality

3. Reduced hospital stay and morbidity

4. Better ‘Q O L’

5. Protection against recurrence

6. Prolong survival if possible

The two ends in Surgery…….

• Transhiatal Oesophagectomy

• En-bloc oesophagectomy with two or three field

lymphadenectomy

Access –OPEN

• Thorax – Abdomen(Iwor Lewis)

• Thorax – Abdomen – Neck(McKeown)

• Thoracoabdominal(Sweet procedure)

• Transhiatal(Orringer)

Access -MAS

• Thoracoscopy & Laparotomy

• Laparoscopy and Thoracotomy

• VATS & Laparoscopy

• Total MIS

How much clearance?

Axial

Radial

Nodal

OPENIvor Lewis

McKeown

Mckeown : Neck Anastomosis

Mckeown: Post op

Mckeown: Post op

Trans hiatal Esophagectomy

THE: Gastric Tubularisation

THE: Neck Dissection

THE: Neck Anastomosis

THE : Specimen

VATS

Placement of ports

Azygos vein being ligated

Mobilisation of Oesophaguswith tumor

Laparoscopic Mobilisation

Lap mobilisation stomach

Gastric conduit being created

Taking up of conduit

Specimen delivered through the neck

Neck Anastomosis

Adjacent organs

• What can be removed ?

–Pleura

–Pericardium

–Diaphragm

–Crura

–Thoracic duct with lymphnodes

Adjacent organs

• What cant be removed?

–Aorta

–Trachea

–Bronchus

–RLN

Lymphadenectomy

• How much to do?– 2 field(mediastinal/abdomen)

– 3 field(mediastinal/abdomen/neck)

Lymphadenectomy

• Number , Region or Both?

3 F L N D

Adheres to oncological principles

LymphadenectomyAt what expense ?

Morbidity and Mortality

Complications - 2 F L N D

n Leak Pulmonary RLN

Injury

Death

Lerut et al. 54 12 11 - 7.4

Nishihara et al. 30 8 13 - 7

Altorki 78 13 24 4 5.1

Fujita 65 11 49 48 3

T H E Complications

n Year leak R L N Pulmon

aryDeath

Orringer MB 800 2001 13 7 2 4

Gupta 250 1996 15 14 3 6

Tilanus 141 1993 26 16 17 5

Vigneswaran 131 1993 24 12 12 2.3

Q O L ?

Which procedure to choose ?1.THE2.TTE3.MAS

44 Series 1986-1996

• 2675 THE

• 2808 TTE

No difference in mortality and

long term survival

Simon Law & John Wong, 2001

• Altorki et al (non randomised trial)

– 4 yr survival – Enbloc esophgectomy

– 37% - TTE vs 11% THE

• Hulscher et al 2002(RCT)

– RCT : TTE vs THE

– 5 yr survival

– TTE: 39% THE: 27% p= 0.08

– MARGINAL STATISCAL SIGNIFICANCE

– Morbidity upto 60% for TTE

Issues for Enbloc Esophgectomy

• Increase time of surgery and anesthesia

• Prolonged Post op ICU Stay

• Length of hospitalisation >14 days

• Morbidity significantly higher

– needs close monitoring with various specialists

• Mortality – similar (TTE vs THE)

• Survival – marginally better

– (Altorki et al and Skinner et al )

• ?QOL

Justification for T H E

Subtotal oesophagectomy possible

Adjacent organ removal

Abdominal and lower mediastinal node removal

(PINOTTI)

Relief of dysphagia

BETTER Q O L

Justification for T H E

Avoiding Thoracotomy

Has it made any difference ?

Hulscher JBF et al. T H E has lower pulmonary complications…

N Eng J Med 2002;347:1662-69

Review of Minimal Access

Palanivelu et al 2006

J Am Coll Surg 2006 Vol :203 (1) : 7 -16

Minimally Invasive Esophagectomy : Thoracoscopic

mobilisation of the EsophagusAnd Medicastinal

Lymphadenectomy in prone Position :

Experience of 130 patients

Palanivelu et al 2006

• Respiratory complications: Very minimal

• Anastomotic leak 2.31 %

• Peri- operative mortality 1.54%

• Median Hospital stay : 8Days

• No tracheal/ lung injury

• Stage specific survival was similar

– between open/MAS at 20 months fU

MAS

• It has potential to replace

other convential type of Eosphagectomies

To be studied

• RCT for

– THE vs MAS

– TTE vs MAS

Thank you