GI - Gastric cancer, Esophageal cancer, GIST Flashcards
Gastric Cancer
- Most common histological subtypes
- Distribution in location
- Mode of spread
Histology:
- Adenocarcinoma (95%) - Lauren’s classification into Intestinal, Diffuse, Mixed subtypes
- Gastric neuroendocrine tumours from ECL cells
- Gastric MALT lymphoma
- GIST
- Linitis Plastica
Distribution in location:
Proximal (30%), Middle (30%), Distal (40%)
Recent proximal migration of tumours
Mode of spread:
- Haematogenous: Liver, lung
- Direct: Upper GI organs, Colon, Kidneys and adrenals, Diaphragm
- Lymphatic spread: Peri-gastric - Celiac axis - Para-aortic LN
- Trancoelomic spread: Peritoneal carcinomatosis, Sister Mary Joseph Nodule, Krukenberg’s tumor, Blumer’s shelf
Linitis plastica
- Pathology
- Diagnosis
- Prognosis
Poorly-differentiated diffuse type gastric cancer
Diagnosis:
- Difficult insufflation on OGD (sign)
- Strip and bite biopsy technique (not superficial mucosal biopsy) on OGD
- Cross-sectional imaging by CT abdomen
Prognosis:
- Poor, presents late
- 1/3 with early metastasis to peritoneum/ malignant ascites
- Microscopic disease at surgical margins
Gastric cancer risk factors
Non-modifiable:
- Old age, Male sex, Asian ethnicity
Disease:
- Gastric ulcers
- Atrophic gastritis
- Adenomatous polyps
- Biliary reflux causing intestinal metaplasia
- Menetrier’s disease (protein-losing hypertrophic gastropathy)
Family history:
- Gastric cancer
- Hereditary diffuse gastric cancer (E-cadherin mutation)
- FAP, HNPCC (Lynch syndrome)
Modifiable risk factors:
- Diet: nitrates, nitrosamine in pickled food, smoked and salted food, Low selenium/ Vit C/ fruits and vegetables
- Social: Smoking, Alcoholism, Low socio-economic status, obesity
- Surgical: previous partial gastrectomy or GJ causing long-term biliary reflux and chronic gastritis
Blood and nerve supply of stomach
Arterial:
- Greater curvature: Short gastric a., Left and right gastro-omental/ gastro-epiploic a.
- Lesser curvature: Left and right gastric a.
Venous: SMV
Nerve:
- Sympathetic: Greater splanchnic nerve from T5-9
- Parasympathetic: Anterior Vagus for stomach, pylorus and liver; Posterior Vagus for Stomach, Foregut and midgut down to splenic flexure of colon
Gastric Polyps
- Types
- Respective malignant potential
- Management
Types:
- Adenomatous (premalignant): >2cm correlate with 24% incidence of malignancy. Associated with FAP correlate with 10x incidence of malignancy
- Fundic gland polyp (not pre-malignant/ no malignant potential): a/w long-term PPI use
- Hyperplastic polyp(Minimal malignant potential): Most common type, large polyp >2cm correlates with dysplasia, CIS and gastric cancer development
- Inflammatory polyp (no malignant potential)
- Hamartomatous polyp (no malignant potential)
Management:
- ALL polyps >1cm removed by polypectomy via OGD
- Polyp sample sent to confirm histological diagnosis
- Surgical resection with 2-3cm margin performed laparoscopically or endoscopically if excision by OGD is impossible
Gastric cancer
TNM staging
Tumour may penetrate muscularis propria with extension into the gastrocolic or gastrohepatic ligaments, or into the greater or lesser omentum, without perforation of the visceral peritoneum covering these structures = Classified as T3
Tumour that has perforation of visceral peritoneum covering the gastric ligaments or the omentum = Classified as T4
Adjacent structures of stomach include the spleen, transverse colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland, kidney, small intestine and retroperitoneum
Intramural extension to duodenum or esophagus is NOT considered invasion of adjacent structure but is classified using the depth of the greatest invasion in any of these sites
Classification system for EGJ and gastric cardia cancers
AJCC/ UICC TNM staging
* Tumors involving the EGJ with the tumor epicenter no more than 2 cm into the proximal
stomach are staged as esophageal cancer
* EGJ tumors with their epicenter located more than 2 cm into the proximal stomach are staged as stomach cancer
Siewert classification:
Type I = Located between 5 and 1 cm proximal to anatomical Z-line
- Adenocarcinoma of distal esophagus/ Barrett’s esophagus infiltrating EGJ
- Treatment = Transthoracic en bloc esophagectomy + Partial gastrectomy + 2-
field lymphadenectomy
Type II = Located between 1 cm proximal and 2 cm distal to the anatomical Z-line
- True gastic cardia cancer
- Treatment = Transabdominal/ Transhiatal resection of the distal esophagus + Total gastrectomy + Lymphadenectomy of the lower mediastinum and the abdominal D2 nodal compartment
Type III = Located between 2 and 5 cm distal to anatomical Z-line
- Subcardial gastric cancer infiltrates EGJ
- Treatment = Transabdominal/ Transhiatal resection of the distal esophagus + Total gastrectomy + Lymphadenectomy of the lower mediastinum and the abdominal D2 nodal compartment
Gastric cancer
Macroscopic classification
Borrmann’s classification:
- Type 1 polypoid
- Type 2 fungating
- Type 3 ulcerated
- Type 4 diffusely infiltrative
Japanese Society for Gastroenterological Endoscopu (JSGE)
- Type 1 Polypoid: Pedunculated, Subpendunculated, Sessile
- Type 2 flat: superficial elevated, flat, flat depressed
- Type 3 ulcerated
- Type 4 lateral spreading tumour
Gastric cancer
Histological classification
Adenocarcinoma - Lauren classification
1. Intestinal type: Well-differentiated, less aggressive, predeliction to haematogenous spread, sequalae of H. pylori induced atrophic gastritis and intestinal metaplasia
2. Diffuse type: Undifferentiated, aggressive with poor prognosis, transmural and lympatic spread likely, Signet ring cells with intracellular mucin
Non-AD gastric cancer:
- Carcinoid tumours (ECL cells): Zollinger-Ellison syndrome; MEN1 syndrome
- Gastric MALT lymphoma: H. pylori chronic gastritis
- GIST: c-KIT (most) or PDGFRA gene mutation
Gastric cancer
Clinical features
S/S:
- Epigastric pain
- Dysphagia: proximal gastric cancer
- Early satiety: proximal gastric cancer, GOO
- Nausea/ Vomiting + Succussion splash: GOO from distal gastric cancer
- Haematemesis or tarry stool +/- anaemia: Chronic GIB with IDA
- Constitutional symptoms: anorexia and weight loss, cachexia
- Malignant gastrocolic fistula: colonic obstruction, feculent emesis, passage of undigested food in stool
Metastatic S/S:
- Dyspnea: Lymphangitis carcinomatosis
- Jaundice, hepatomegaly: Liver met
- Abdominal distension: Malignant ascites
- Lymphadenopathy: Left supraclavicular adenopathy (Virchow’s node), Left axillary node (Irish node), Periumbilical node (Sister Mary Joseph’s node)
- Blumer’s shelf, Krukenberg tumour
Gastric cancer
Compare early, intermediate and late symptoms
Paraneoplastic syndromes
Seborrheic keratosis (Leser-Trelat sign)
Acanthosis nigricans
* Hyperpigmentation of axilla and groin
Hypercoagulability
* Migratory superficial thrombophlebitis (Trousseau’s syndrome)
* Deep vein thrombosis (DVT)
Gastric cancer
Investigations
Biochemical:
- CBC with differential: McHc anaemia from IDA
- Clotting profile
- RFT with electrolytes: Membranous nephropathy (paraneoplastic nephrotic syndrome) + assess metabolic alkalosis if severe vomiting due to GOO
- LFT: liver met, biliary obstruction, nutritional status
- Tumour marker: treatment response and prognostic marker only
Imaging:
- Oesophago-gastro-duodenoscopy (OGD) + Biopsy: Histological diagnosis
- (Double-contrast barium meal: for linitis plastica/ infiltrating lesion only)
T/N staging:
- Endoscopic ultrasound (EUS): T/N staging for depth of invasion, perigastric and celiac LN staging
M staging:
- CT throax, abdomen, pelvis (CT T+A+P): M staging for distant metastasis, distal nodal spread and malignant ascites
- PET-CT scan: M staging and confirm CT-detected lymphadenopathy
- Staging laparoscopy + peritoneal cytology: M staging for EUS stage T3/4, detection of small volume liver and peritoneal metastasis
- CXR: M staging for Pleural effusion, Lymphagitis carcinomatosis
Gastric cancer
Treatment options
Palliation:
Bleeding:
- Transcatheter embolization
- External beam radiotherapy (EBRT)
- Palliative gastrectomy
Gastric outlet obstruction
- Endoscopic laser ablation
- Endoscopic self-expanding metallic stent placement
- Palliative gastrectomy
- Palliative bypass with gastrojejunostomy
Medical:
Neoadjuvant chemotherapy: 5-Fluorouracil (5-FU) + Epirubicin + Cisplatin
- Indicated in T3 (transmural) tumours or N1 tumours (LN involvement)
Adjuvant chemotherapy: 5-Fluorouracil (5-FU)/ Leucovorin + Radiation therapy
- Indicated for ALL patients EXCEPT T1-2, N0,M0
Endoscopic treatment:
- Endoscopic mucosal resection (EMR) / Endoscopic submucosal dissection (ESD en bloc resection)
- Indicated for tumour <2cm, LN negative, confined to mucosa on EUS exam
Surgery:
- Gastrectomy + Lymphadenectomy + reconstruction
- Indicated for M0, No major vascular invasion
Gastric cancer surgical treatment
Indicators of unresectability
Extent of gastrectomy
Extent of lymphadenectomy
Unresectable:
- Presence of distant metastasis
- Invasion of major vascular structure including aorta
- Encasement or occlusion of hepatic artery, celiac axis or proximal splenic artery
Extent of gastrectomy:
- Gross negative margin ≥ 5 cm
- En bloc resection of adjacent involved organs such as distal pancreas, transverse colon or spleen is indicated in T4 tumours
Different extent of lymphadenectomy
- D1 lymphadenectomy = Perigastric LNs dissection
- D2 lymphadenectomy (STANDARD) = D1 + Removal of LNs along celiac trunk, common hepatic, splenic, left gastric arteries and those LNs in splenic hilum
- D3 lymphadenectomy = D2 + Removal of LNs in porta hepatis and periaortic regions
STANDARD D2 lymphadenectomy: removes 15 LNs: improves disease-specific survival, accurate N staging, minimize stage migration
Gastric Cancer
Types of gastrectomy and indications
Components resected
Advantages
Proximal tumours (e.g. EGJ/ Cardia tumour) = Total gastrectomy
Midbody tumours = Total gastrectomy
Distal tumours = Subtotal gastrectomy (decreased surigcal complication, improve nutritional and QoL)
Gastric cancer
Gastrointestinal reconstruction
- Types
- Indications
- Specific side effects
Billroth I:
- End-to-end gastroduodenostomy
- Indication: Proximal gastric remnant and duodenal stump can be joined without tension after antrectomy
- Preserve duodenum and jejunum
- S/E: Bile reflux gastritis/ Alkaline gastritis, Dumping syndrome
Billroth II:
- End-to-side gastrojejunostomy
- Indication: Billroth I not possible, like extended distal gastrectomy
- Preserve jejunum
- S/E: Malabsorption, Bile reflux gastritis, Dumping syndrome, Afferent/ Efferent loop syndrome
Roux-en-Y:
- Esophagojejunostomy/ Gastrojejunostomy
+ Jejunojejunostomy
- Indication: Billroth I not possible, like very extended distal gastrectomy; or better QoL
- No structure preserved
- S/E: Malabsorption, (NO bile reflux because of diversion), Dumping syndrome, Roux Stasis Syndrome
Dumping syndrome
Pathophysiology
Presentation
Treatment
Pathophysiology:
- Destruction or bypass of pyloric sphincter leads to rapid gastric emptying of hyperosmolar carbohydrates load (chyme)
- Osmotic gradient draws fluid into intestine (rapid shift of ECF into bowel lumen) and release vasoactive hormones
- Vasoactive hormones cause reactive postprandial hyperinsulinemia and subsequently hypoglycemia
- Most common after Billroth II reconstruction due to loss of reservoir capacity and pylorus function
Presentation:
- nausea, epigastric discomfort, abdominal cramps, explosive diarrhea
- vasomotor symptoms including sweating, palpitation and flushing
Treatment:
- converted to Rouxen-Y gastrojejunostomy
- small frequent meals
- liquid ingestion 30 mins after eating solids
- avoidance of simple carbohydrates
Gastrectomy
Specific complications
- Malnutrition: Vitamin B12, Fat-soluble vitamin, Iron deficiency
- Bile reflux gastritis: treat with antacids, cholestyramine or convert to Roux-en-Y GJ
- Dumping syndrome
- Afferent loop syndrome (Billroth II only):
- SB IO of afferent limb due to kinking, anastomotic narrowing, adhesions, volvulus or internal herniation
- post-prandial epigastric pain, nausea and non-bilious vomiting
- complications including duodenal stump blowout, obstructive jaundice, ascending cholangitis and pancreatitis - Efferent loop syndrome (Billroth II only):
- intermittent obstruction of efferent limb of the gastrojejunostomy, presents as SB IO - Roux-Stasis syndrome:
- Functional IO due to disruption of normal propagation and propulsive activity in Roux limb; retrograde propulsion of food causes vomiting and chronic abdominal pain - Early satiety: Small reservoir volume
- Post-vagotomy diarrhea:
- uncoordinated gastric emptying, biliary secretion and SB movement
- Treat with decrease fluid intake, food with lactose
- Antidiarrheal medications
Gastric cancer
Acute complications
Bleeding
* Iron-deficiency anemia
* Hematemesis and melena
Gastric outlet obstruction (GOO)
* Presents with abdominal distension, vomiting
* Risk of dehydration and electrolyte abnormalities including hyponatremia, hypokalemia and metabolic alkalosis
* Risk of aspiration pneumonia
Perforation
* Leads to peritonitis
GIST
Types
Common locations
Origin
Stromal and mesenchymal neoplasm affecting the GIT
- gastrointestinal stromal tumours (GIST)
- other soft tissue tumours: lipoma, liposarcoma, leiomyoma, leiomyosarcoma, desmoid tumour, chwannoma and peripheral nerve sheath tumour
Common locations: esophagus to anus
* Stomach (40 – 60%)
* Jejunum/ Ileum (25 – 30%)
* Duodenum (5%)
* Colorectum (5 – 15%)
* Esophagus (≤ 1%)
* Extra-gastrointestinal stromal tumour (EGIST): Omentum/ Mesentery/ Retroperitoneum
Origin: interstitial cells of Cajal (ICC) in muscularis propria, thus smooth muscles and neuronal differentiation
GIST
Biological behaviour
Associated genetic
Associated conditions
Biological behavior: “potentially malignant”, not true malignant tumour
- Frequently metastasize to liver, peritoneum, omentum
- Rarely metastasize to regional LNs
- Rarely metastasize to lung
Genes:
- (80%) KIT gene mutation
- (10%) PDGFRA gene activating mutation
- (10%) Wild-type: neither KIT or PDGFRA
Conditions (mainly wild-type tumours)
* Neurofibromatosis type 1 (NF1)
* Carney-Stratakis syndrome
* Carney triad (GIST + Pulmonary chondroma + Extra-adrenal paraganglioma)
GIST
Molecular markers
Histopathology of GIST
- CD117 antigen (95%): part of the KIT transmembrane receptor tyrosine kinase that is the product of the KIT (c-kit) protooncogene
- CD34 antigen (~66%): Neither selective nor specific for GIST
- DOG-1(~100%): Near-universal expression in all GIST including KIT -ve PDGFRA-mutant tumour
GIST
TNM staging
GIST
Clinical presentation
Signs and symptoms
Upper GI bleeding: MOST common clinical presentation
Abdominal pain
Abdominal mass
Early satiety
Bloating sensation
Tumour can act as an intramural cause of obstruction or as a lead point for intussusception
* Abdominal pain
* Abdominal distention
* Vomiting
* Constipation
GIST
Investigations
Radiological tests
- Endoscopic USG + Fine needle aspiration (FNA): cytology analysis + Immunohistochemistry for KIT mutation is diagnostic
- Indicated: Neoadjuvant Imatinib is considered before attempted resection of large, locally advanced lesion (likely to be GIST)
- Surgically unresectable disease, only using Imatinib
- Metastatic disease, only using Imatinib
OGD:
- Mass woth smooth margins, normal overlying mucosa, bulging into gastric lumen with/ without obstruction
- Biopsy is NOT diagnostic
CT/ MRI scan: for staging mass character, extent, any metastasis
PET scan: high metabolic area (cannot diagnose, cannot replace CT)
GIST
Treatment options
Targeted therapy
- Tyrosine kinase inhibitor (TKI): Imatinib/ Sunitinib
- Neoadjuvant imatinib: upper GIT or distal rectal GIST; increase resectability
- Adjuvant imatinib: high risk relapse/ GIST > 3cm in size
- Palliative imatinib: metastatic GIST
Surgical resection:
- Exploration by laparatomy
- Indicated for all GIST ≥ 2 cm
- GIST < 1 cm can be follow-up conservatively
- No need for LN dissection
Esophageal Cancer
- Histological subtypes
- Modes of spread
SCC or AD
- Upper 2/3 SCC
- Distal 1/3 AD (Barrett’s esophagus)
Modes of spread:
* Direct spread (e.g. trachea leading to tracheoesophageal fistula)
* Lymphatic spread
* Hematogenous spread
Metastasis to organs including
* Lungs
* Liver
* Bones
* Adrenals
Esophageal cancer
Risk factors for SCC and AD
Risk factors of squamous cell carcinoma (SCC)
- Smoking
- Alcoholism
- Dietary factors
* Restricted diet of salted fish and pickled vegetables
* Vegetables and citrus fruit deficiency
* Trace elements deficiency (e.g. Selenium)
* Fungal contaminants (e.g. Aflatoxin)
- Underlying esophageal disease
- Achalasia
- Caustic (ingestion) strictures e.g. bleach/ acid
- History of H&N cancer: high risk of synchronous tumours
- Prior radiation due to H&N tumour
- Genetic: Peutz-Jegher syndrome, PTEN mutation, Plummer-VInson syndrome
- HPV infection
Risk factors of adenocarcinoma
- Smoking (not alcohol)
- Obesity and metabolic syndrome
- Family history
- Gastroesophageal reflux disease (GERD) and Barrett’s metaplasia
- Barrett’s esophagus
Esophagus
Anatomical divisions
Characteristics of esophagus
* Esophagus is a muscular tube that is 25 cm in length
* Begins at cricoid cartilage (at level C6) to stomach (at level T10)
* Upper esophageal sphincter (UES) is formed by cricopharyngeus muscle
* Lower esophageal sphincter (LES) is NOT an anatomical sphincter but physiological
Histological features of esophagus
* Outer longitudinal and inner circular layer
* Lined by non-keratinizing stratified squamous epithelium
Neurovascular supply of esophagus
Esophageal cancer
TNM staging
Esophageal cancer
Anatomical classification for OGJ/ proximal stomach cancer
AJCC/ UICC TNM staging
* Tumors involving the EGJ with the tumor epicenter no more than 2 cm into the proximal
stomach are staged as esophageal cancer
* EGJ tumors with their epicenter located more than 2 cm into the proximal stomach are staged as stomach cancer
Siewert classification:
Type I = Located between 5 and 1 cm proximal to anatomical Z-line
- Adenocarcinoma of distal esophagus/ Barrett’s esophagus infiltrating EGJ
- Treatment = Transthoracic en bloc esophagectomy + Partial gastrectomy + 2-
field lymphadenectomy
Type II = Located between 1 cm proximal and 2 cm distal to the anatomical Z-line
- True gastic cardia cancer
- Treatment = Transabdominal/ Transhiatal resection of the distal esophagus + Total gastrectomy + Lymphadenectomy of the lower mediastinum and the abdominal D2 nodal compartment
Type III = Located between 2 and 5 cm distal to anatomical Z-line
- Subcardial gastric cancer infiltrates EGJ
- Treatment = Transabdominal/ Transhiatal resection of the distal esophagus + Total gastrectomy + Lymphadenectomy of the lower mediastinum and the abdominal D2 nodal compartment
Esophageal cancer
Clinical features
Dysphagia: Mechanical obstruction
Odynophagia: late disease, indicate extra-esophageal involvement
Reflux: tumour invade nerve plexus, aspiration pneumonia risk
Haematemesis/ Melena: bleeding from primary tumour/ erosion into aorta or pulmonary vessels
Anaemic symptoms: Pallor, palpitation, dyspnea, fatigue
Constitutional symptoms: Anorexia, Unintentional weight loss, lymphadenopathy
Locally advanced disease:
- Hoarseness: Left RLN invasion
- Choking/ Cough/ Fever: Tracheoesophageal fistula and aspiration pneumonia
- Horner’s syndrome
Distant met:
- Cough/ Dyspnea/ Hematemesis: Lung
- Jaundice/ RUQ pain/ Ascites: Liver
- Chronic spinal pain: bone
Esophageal cancer
Investigations
Biochemical:
- CBC with differential
- Clotting profile
- RFT and electrolyte profile: vomiting, contrast, pre-renal causes of dehydration
- LFT: nutritional status, liver met
- Lung function test, ECG, ECHO: Cardiopulmonary fitness for surgery
Imaging:
- CXR: Lung met, pleural effusion, aspiration pneumonia, soft-tissue mass e.g. bronchogenic carcinoma causing dysphagia
- Barium swallow: tracheoesophageal fistula, demonstrate proximal dilatation/ mucosal irregularity/ annular constriction
OGD with biopsy:
- Chromoendoscopy with Lugol’s iodine: Normal squamous epithelium with glycogen will mix with iodine and stained black,
dark-brown or green brown; Dysplasia or SCC do not stain
- Narrow-band imaging: detailed inspection of vascular and mucosal patterns for prediction of histology
- Bronchoscopy: only for TE fistula, upper and middle 1/3 of esophagus
T/N staging:
- Endoscopic ultrasound +/- LN FNAC: depth of invasion and regional LN spread
- CT thorax + abdomen: distinguish T4 lesions
M staging:
- CT thorax + abdomen
- PET-CT scan
- Laparoscopy
Esophageal cancer
Treatment options
Medical:
- Radical radiotherapy
- Neoadjuvant chemotherapy and adjuvant chemoradiation
Surgical:
- Endoscopic mucosal resection (EMR): Snare resection of dysplastic lesion
- Endoscopic submucosal dissection (ESD): Dissect lesions from the submucosa
- Indication: Dysplasia (Tis) or Superficial cancer that are limited to mucosa (T1a)
Surgery:
- Trans-thoracic: Lewis-Tanner (2 stage) or McKeown (3-stage)
- Transhiatal approach
- Lymphnode dissection: Field 1 Cervical, Field 2 Mediastinal, Field 3 abdominal
- Indication: T1b or above, resectable disease
Esophageal cancer
Compare surgical techniques procedures
Transthroacic approach
1. Lewis-Tanner/ Ivor-Lewis (2-stage:
- Stomach is mobilized through a midline abdominal incision to attain tension free and well-vascularized portion for transpition, cardia and upper lesser curvature with left gastric artery and LN resection
- Right thoracotomy above 5th rib to access esophagus for Esophagectomy and esophago-gastric anastomosis
- McKeown:
- Stomach is mobilized through a midline abdominal incision to attain tension free and well-vascularized portion for transpition, cardia and upper lesser curvature with left gastric artery and LN resection
- Right thoracotomy above 5th rib to access esophagus for Esophagectomy
- Neck incision is performed for Cervical esophagogastric anastomosis
Transhiatal/ Blunt esophagectomy/ Esophagectomy without throacotomy:
- Stomach is mobilized through a midline abdominal incision
- Diaphragm is opened from the abdomen and posterior mediastinum is entered
- Lower esophagus and tumour is mobilized under direct vision and upper esophagus is mobilized by blunt dissection
- Esophagectomy is performed and translocation of stomach to perform a cervical esophagogastric anastomosis through a neck incision
- DOES NOT remove LN in upper or middle mediastinum
Esophageal cancer
Surgical treatment option
Indication for each approach
Transthoracic:
1. Lewis-Tanner: Most common
- tumour in distal 1/3 of esophagus or
intraabdominal region
- Anastomosis is inside the intrathoracic cavity; thus anastomotic leakage can be detrimental, causing mediastinitis or pleuritis
- McKeown
- More appropriate for more proximal tumour, also suitable for distal 1/3 esophagus
- Anastomosis is inside the cervical region
- Complication like anastomotic leakage is easier to be managed by percutaneous drainage
Transhiatal:
- Unsuitable for most CA esophagus since complete mediastinal lymphadenectomy cannot be achieved
- Thoracotomy is NOT required which is associated with fewer pulmonary complications
- Indicated for other diseases e.g. refractory late stage achalasia, caustic agent ingestion
Esophageal cancer
Fields of LN dissection
Standard procedure
Different fields of dissection
- Field 1 = Cervical LN
- Field 2 = Mediastinal LN
- Field 3 = Intra-abdominal (celiac) LN
Standard two-field dissection for majority of tumours
- Upper 1/3 (e.g. SCC) = Field 1 and 2 dissection
- Lower 1/3 (e.g. AD) = Field 2 and 3 dissection
Radical 3-field dissection:
- Indicated for extensive SCC that emcompass upper and middle thirds of esophagus
Esophagectomy
Medical complications
Pulmonary complications
* Atelectasis
* Pneumonia
* Bronchospasm
* Acute respiratory distress syndrome (ARDS)
* Acute exacerbation of COPD
* Pulmonary embolism
* Respiratory failure
Cardiac complications
* Atrial fibrillation (AF)
* Myocardial infarction
Esophagectomy
Specific surgical complications
Conduit complications
- Anastomotic leak: Manage by NPO for 5-7 days, PEJ tube feeding from Day 2, Gastrograffin swallow to check leak at Day 7, Open drainage for cervical anastomosis
- Anastomotic stricture
- Conduit ischemia
Chylothorax:
- Puncture of thoracic duct
- Presence of triglycerides > 110 mg/dL or chylomicrons in pleural fluid
- Close monitoring of chest tube output, change to MCT or SCFA nutrition, rehydration, avoid LCFA in diet
- Right thoracotomy with retraction of conduit and ligation of thoracic duct
RLN injury: hoarseness and aspiration pneumonia
Functional disorders:
- GERD, Dysphagia, Delayed gastric emptying
Esophagectomy
Post-op prevention of complications
Unresectable esophageal cancer
Palliative treatment options
Indications
* Patients with metastatic cancer
* Cancers invading adjacent organs that is unresectable (T4b)
Options of palliative treatment
* Esophageal dilation with stenting: NOT suitable for tumours long in size due to poor functional peristalsis or located in cervical esophagus due to discomfort
* Endoluminal laser technique: restore lumen patency
* Radiotherapy: external beam irradiation or brachytherapy; indicated for SCC (radiosensitive) or palliation of EGJ cancers to avoid stenting and subsequent reflux
* Chemotherapy: 5-FU and Cisplatin based
* Nutritional support: Percutaneous endoscopic gastrostomy (PEG) or jejunostomy tube (PEJ)
