Oesophageal Cancer Surgery
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The oesophagus (food pipe/gullet) is a muscular tube that connects the mouth to the stomach. There are two main types of oesophageal cancer:
• Squamous Cell Carcinoma (SCC) – this develops from the normal squamous lining of the food pipe
• Adenocarcinoma – this develops from glandular cells found in Barrett’s Oesophagus.
Oesophageal SCC has a higher global incidence, whereas adenocarcinoma has a higher incidence in the Western population.
Oesophageal cancer is the eighth most common malignancy worldwide. In the UK, around 9000 people are diagnosed with oesophageal cancer each year. It usually affects the 50-70 year age group and is more common in males than females.
1. Gastro-Oesophageal Reflux Disease predisposes to Barrett’s Oesophagus and is a significant risk factor for the development of adenocarcinoma. Patients with Barrett’s have a 30-fold increased risk of developing adenocarcinoma in comparison to the general population; however their absolute annual risk is only 0.12%.
2. Obesity is an independent risk factor and is also related to GORD, increasing the chance of developing adenocarcinoma by 3 to 6 folds.
3. Current smokers have a 2 to 4 fold increased risk of developing adenocarcinoma.
Squamous Cell Carcinoma:
1. Current smokers have a nine-fold increased risk of developing SCC in comparison to the general population.
2. Moderate to high alcohol consumption has also been shown as an independent risk factor for SCC. The European Prospective Investigation into Cancer and Nutrition (EPIC) reported an increase risk of 35% for women and 18% for men, per 10g/day alcohol consumption.
3. A diet low in fruit and vegetables is also a significant risk factor
Oesophageal cancer is often detected at an advanced stage, with only 30% of patients amenable to curative treatment at the time of presentation. Signs and symptoms may remain absent during the early stages of cancer, making diagnosis difficult.
In the UK patients above the age of 55 or with alarm symptoms, are referred for rapid access endoscopy. The following alarm symptoms are associated with oesophageal cancer in order of frequency:
• Dysphagia The sensation of food getting stuck on swallowing
• Reflux New onset reflux symptoms in those over the age of 55
• Weight loss Occurs in ~20% of people
• Anaemia Low Red Blood Cells due to bleeding from the tumour
• Pain Epigastric/retrosternal pain
Upper Gastro-intestinal Endoscopy and biopsy is the investigation of choice for diagnosis of oesophageal cancer. A minimum of 6 biopsies is recommended for accurate histological confirmation. Endoscopy can also be augmented by Chromoendoscopy and Narrow Band Imaging (NBI).
Treatment recommendations will be undertaken by a dedicated Upper Gastrointestinal Multi-disciplinary Team (MDT). The team meets once a week to discuss patients with oesophageal and gastric cancers to ensure the correct treatment is given. The MDT is attended by multiple specialists including: Medical Oncologists, Clinical Oncologists, Radiologists, Surgeons, Gastroenterologists, Histopathologist, and Specialist Nurses.
The decision for treatment will fall into two categories: treatment with an intent to cure and treatment with an intent to palliate (not curative but with an intended purpose to extend life and relieve symptoms). This decision is based on the findings of the staging investigations, patient co-morbidities, nutritional status and patient preferences.
Curative treatment often involves Chemo/radiotherapy in combination with surgery. Median Five year survival of treatment with curative intent is approximately 45-50%.
The purpose of pre-treatment staging is to identify the depth of infiltration of the tumour into the oesophageal wall (T stage), the presence of regional lymph node metastases (N stage) and distant metastases (M stage). A combination of imaging modalities is used to determine the TNM stage. The TNM Stage can then be used to select appropriate patients for curative or palliative treatment modalities. Metastases is the spread of tumour to sites away from the primary tumour.
• CT (Computer tomography) of the chest/abdomen/pelvis
CT is often the initial staging investigation and takes about 15 minutes to perform. It is useful for detecting metastases in solid organs and distant lymph nodes. Detection is dependent on size of the lesion and there are also limitations in distinguishing metastatic from inflammatory enlargement.
• FDG-PET-CT (18F-fluoro-2-deoxy-D-glucose - Positron Emission Tomography - Computed Tomography)
Cancers preferentially uptake glucose for their metabolism. FDG-PET-CT involves injecting radio-labelled glucose into the bloodstream to highlight foci of cancer in the body. It improves the diagnostic capability of detecting smaller/occult metastases by 20% in comparison to CT alone. The procedure is very similar to CT but takes longer and you will be asked to starve for 6 hours before hand
• Endoscopic ultrasound (EUS)
This is a similar procedure to the endoscopy, except the probe has an ultrasound device on the end, which enables the doctor to examine the cancer and surrounding tissue in precise detail. It takes longer than an endoscopy and may require more sedation. EUS is the preferred imaging modality for clarification of the T stage and local lymph node involvement. In addition suspicious lymph nodes can be biopsied for histological confirmation.
• Staging laparoscopy
A keyhole examination of the abdomen under general anaesthetic is used for the detection of metastases that cannot be detected with scans. It also allows the surgeon to look at local invasion of the tumour into surrounding organs. The procedure is quick and patients usually go home on the same day.
Oesophagectomy is the main surgical treatment for esophageal cancer. It is performed to remove the cancer and the lymph nodes around it. During an Oesophagectomy, the surgeon removes all or part of the oesophagus through incisions in the neck, chest or abdomen. The oesophagus is replaced using another organ, most commonly the stomach but occasionally the small or large intestine.
Oesophagectomy can be performed with open surgery or minimally invasive surgery (including laparoscopy or robotic approaches) or a combination of both approaches. Minimal invasive approaches have been shown to reduce pulmonary complications and improve the rate of recovery.
Oesophagectomy is a major operation with a significant risk of morbidity. Post-operative hospital stay will be approximately 7 to 14 days if there is no complication. Potential complications of Oesophagectomy include: bleeding, infection, anastomotic leak, chyle leak, pulmonary complications, organ impairment, venous thrombo-embolism and mortality. These will described in more detail by your surgeon.
To reduce postoperative complications your recovery will be aided by a Prehabilitation Programme and Enhanced recovery Programme (ERP) designed to speed up your recovery and reduce complications.
After surgery you will be looked after in an intensive care unit for the first 5 days. You will have several lines for venous and arterial access, an epidural to control your pain, a naso-gastric tube, several chest drains, and a feeding tube inserted into the bowel (feeding jejunostomy). Other than the feeding jejunostomy the other lines and tubes will be removed sequentially over the next few days. Your oral liquid and food intake will also be reintroduced gradually over the next few days. Multiple teams of healthcare professionals will look after you including surgeons, intensivists, nurses, physiotherapists, dieticians, etc, with an aim to re-establish normal function as soon as possible. The jejunostomy tube will remain for several months after the operation to help supplement your nutrition, especially if you are to undergo chemotherapy after your operation. Post-operative hospital stay will approximately 7 to 14 days if there are no complications.
The most common symptoms experienced by patients include reflux and lethargy and alteration in eating habit which may lead to weight loss. Nutritional supplementation in the form of multi-vitamins will also be required after removal of the feeding jejunostomy.
It will take approximately six weeks before achieving good function and six months for full recovery.
For more information:
Cancer Research UK