Upper GI Surgery JC051: I Can't Swallow: Esophageal Cancer Flashcards
Dysphagia
Dysfunction of clearing of food and drink through oral cavity, pharynx, esophagus into stomach at an appropriate rate and speed
- Oropharyngeal dysphagia:
- difficulty with initial phases of swallowing, from mouth to esophagus - Esophageal dysphagia:
- sensation that foods / liquids are being obstructed in the passage from mouth to stomach
Anatomy
- Tongue, Oropharynx, Upper esophageal sphincter, Upper 5% of Esophagus: Striated muscle (Voluntary)
- Mid 35-40% of Esophagus: Mixed
- Distal 50-60% of Esophagus: Smooth muscle (Involuntary)
(From GIS05 06:
- Muscular tube (~25cm long)
- Conveys food from pharynx to stomach
- behind trachea, heart; adjacent to aorta (danger of penetration)
3 parts:
1. Cervical part (skeletal)
2. Thoracic part (smooth + skeletal)
3. Abdominal part (smooth)
3 constrictions:
1. Upper esophageal constriction (level of cricoid cartilage)
2. Middle esophageal constrictions (level of aortic arch)
3. Lower esophageal constriction (level of diaphragm)
Clinical significance:
- passing instruments through esophagus into stomach
- viewing radiographs in dysphagia patients)
Physiology of swallowing
Peripheral stimuli of oropharynx, larynx, esophagus
—> Sensory neurons (CN5, 7, 9, 10)
—> Cortical and Subcortical structure
—> Brainstem swallowing centre
—> Motor nuclei:
- Oropharyngeal (Trigeminal, Facial, Ambiguus, Hypoglossal, C1-2)
—> CN5, 7, 9, 11, 12, Ansa cervicalis motor neurons
—> Oropharyngeal swallow response - Esophagus (Dorsal motor nucleus)
—> CN10
—> Primary peristalsis
Phases of swallowing
- Oral preparatory phase
- Voluntary
- **Mastication (solid)
- **Glossopalatal seal (fluid): Soft palate closing passage between nasal and oral cavity - Oral propulsive
- Mouth —> Pharynx —> Esophagus
- **Tongue movement push food from mouth to posterior pharynx
- **Epiglottis cover airway, ***Larynx move upwards to cover —> prevent aspiration of food into airway - Pharyngeal
- Involuntary
- Oro-pharyngeal: Relaxation of UES - Esophageal
- Involuntary
- Peristalsis
Manometry
Conventional Manometry:
- test pressure
- 4-8 pressure channels
- water / solid state catheter
- spacing in esophagus 5 cm apart
- spacing in LES 1cm / radial
High Resolution Manometry:
- sensors only 1 cm apart
- 12 circumferencial sensors at each level to test pressure
***Approach to Dysphagia
- Real dysphagia?
- ***Globus hystericus (something sticking in the throat) -
**Oropharyngeal vs Esophageal dysphagia
- **level of obstruction
- ***type of food
- pattern reported
- Esophageal dysphagia patient may perceive location at cervical region mimicking Oropharyngeal dysphagia - ***Mechanical (Anatomical) vs Functional (Motility)
***Oropharyngeal dysphagia
Features:
- Difficulty **initiating a swallowing, repetitive swallowing
- Nasal regurgitation (when soft palate seal not tight)
- **Coughing from aspiration, diminished cough reflex
- Drooling of saliva / food choking (when jaw cannot move properly)
- **Choking
- Dysarthria + Diplopia
- **Halitosis (bad breath, food retained in pharyngeal pouch)
- Recurrent pneumonia
Causes:
Mechanical / Obstructive causes:
- Infections
- **Thyromegaly
- **Lymphadenopathy
- Reduced muscle compliance (Myositis, Fibrosis)
- Eosinophilic esophagitis (Caucasian: treatment by steroids)
- **Head and neck malignancies
- **Surgical / Radiotherapy interventions on tumours —> stricture / cause inadequate saliva production for swallowing
- Cervical osteophytes
- Oropharyngeal malignancy / neoplasms (rare)
- ***Zenker diverticulum
Neuromuscular disturbances:
- CNS disease (**Stroke, Parkinson, CN palsy, **Bulbar palsy (e.g. MS), ALS)
- Contractile disturbance (Myasthenia gravis, Oculopharyngeal muscular dystrophy)
***Esophageal dysphagia
Causes
1. Intraluminal
- **Foreign bodies, **Food bolus
- Mediastinal (obstruct esophagus by direct invasion, compression, LN enlargement)
- ***Tumours (e.g. lymphoma)
- Infections (e.g. TB)
- Cardiovascular (e.g. vascular compression) - Mucosal (narrow lumen though inflammation, fibrosis, neoplasm)
- **Peptic stricture secondary to GERD (repeated esophagitis —> scarring —> stricture)
- Esophageal rings / webs (e.g. Schatzki’s ring)
- **Esophageal tumours
- **Chemical injury (e.g. caustic ingestion: inflammation —> long segment stricture)
- **Pill esophagitis (e.g. NSAIDs, Tetracyclines, KCl (Slow K), Alendronate (Bisphosphonate))
- ***Radiation injury
- Infectious esophagitis (e.g. Herpes virus)
- Eosinophilic esophagitis (Caucasian: treatment by steroids)
- Tumour / Granulation overgrowth in esophageal stenting
(- Epiphrenic diverticulum (~Zenker but in LES)) - Neuromuscular
- **Achalasia
- **Esophageal spasm
- ***Scleroderma - Post-surgical
***Esophageal dysphagia: Mechanical vs Functional
Mechanical:
- Gradual / Sudden onset
- Progress often (e.g. tumour progressively enlarge)
- Worse with swallowing **solid bolus, fluid better
- **Regurgitation in response to bolus
- No temperature
Functional:
- Usually Gradual onset
- Variable progression
- No difference between swallowing solid / liquid bolus (sometimes solid bolus may even stimulate swallowing)
- Bolus can usually passes with drinking liquid / **repeated swallowing
- Vary with temperature of food (*Warm food tends to swallow better)
SpC Case study: Esophageal and Upper Gastrointestinal Surgery
Pathology based on different layers of Esophagus
Epithelium:
- **SCC
- **Adenocarcinoma
- Cyst
- ***Abscess
Submucosa:
- Polyp
- **Schwannoma (Made up solely of Schwann cells)
- **Neurofibroma (May include other kinds of cells, such as mast cells and the axons of nerves, mingled together with collagen bundles and other material)
- Carcinoid tumour
- ***Lipoma
- Haemangioma
(- Lymphoma?)
Muscularis propria:
- **GIST (c-kit (CD117), CD34)
- **Leiomyoma (Desmin, Smooth muscle actin) (SpC PP)
- ***Sarcoma
***Investigations for dysphagia
- VFSS (Video fluoroscopy swallowing study)
- ***Barium swallow (Achalasia: Bird beak / Rat tail sign) - Upper endoscopy
- exclude mechanical obstruction
- ***Oesophago-gastro-duodenoscopy (OGD) - ***FEES (Fibreoptic endoscopic evaluation of swallowing)
-
**High resolution manometry (HRM)
- DCI: distal contractile integral: time x length x intensity
- DL: distal latency (time to take from swallow to contraction of distal esophagus: UES relaxation to the contractile deceleration point (CDP))
—> report as **Pressure
- initiated by ***Swallowing of water - Endoluminal functional lumen imaging probe (EndoFLIP)
- calculated distensibility of esophagus by measuring volume, pressure
—> report as **Diameter
- contraction stimulated by **Secondary peristalsis
—> additional capability over Manometry of measuring the **cross-sectional area and **intraluminal pressure of the esophagus while under distension (as if a solid bolus was present)
Case 1:
- 35yo male
- non-smoker, non-drinker
- chest pain, regurgitation, progressive on/off dysphagia for 1 year
- require flushing with fluid
- weight loss of 20lbs
DDx:
- Achalasia
- Stroke (less likely)
- Distal esophageal spasm
- Reflux stricture (less likely: no symptoms of reflux)
- Ca esophagus (less likely)
1 year —> Functional obstruction
- Achalasia / Distal esophageal spasm
Weight loss 20lb (more severe):
- more likely Achalasia
Case 2:
- 75 yo male
- Chiu Chow ancestry
- chronic smoker and drinker
- progressive dysphagia for 1 month
- weight loss
- regurgitating solid food
- cachexic
- no neck mass
DDx:
- Achalasia
- Stroke
- Distal esophageal spasm
- Reflux stricture
- Ca esophagus
Risk factors:
- smoking + drinking —> SCC
- rapidly progressive history
- weight loss + advanced symptoms —> most likely Ca esophagus
- ***Achalasia
Constant failed relaxation of LES (IRP >= ULN) + Failed esophageal peristalsis (No pressurisation along esophagus)
Type 1 Achalaxia:
- **no pressure at all
- **failed relaxation (high IRP)
Clinical features:
- **Dysphagia: mixed
- **Weight loss
- Cough especially when recumbent
- **Regurgitation / Food stuck
- **Chest discomfort / pain (vigorous achalasia)
Clinical scoring system for Achalasia:
- ***Eckardt score (4 categories: 0-12)
—> Weight loss
—> Dysphagia
—> Retrosternal pain
—> Regurgitation
Easily misdiagnosed as GERD (∵ similar symptoms)
Classification:
1. **Primary
2. **Secondary
- Pseudo-achalasia (Cancer of GEJ)
- Para-neoplastic syndrome
- Infiltrative disorders (amyloidosis, sarcoidosis)
- Chagas’ disease (Flagellate protozoan, Trypanosoma Cruz)
Investigations:
(1. CXR
- Absence of air fluid level in stomach)
- Endoscopy
- Dilated esophagus
- Retained food residue
- LES appear tight but can relax
- Up to 40% “normal”
- Possibility of malignant stricture (pseudoachalasia) - Barium swallow
- Fluid level
- Failed relaxation of LES (but is dynamic vs fixed obstruction by tumour) - ***High resolution manometry (HRM)
- Gold standard
- Chicago classification of Achalasia (Prognostic)
Treatment:
1. ***Botox injection at sphincter
- temporary effect
- reserved for poorly morbid patients who cannot withstand invasive intervention / when diagnosis is not confirmatory
- inhibit ACh release —> paralyse + relax LES
- ***Endoscopic dilatation by balloon
- break down circular muscle - Surgery: **Heller myotomy (cut away LES)
- SE: Acid reflux —> **Dor fundoplication (a partial wrapping of the stomach around the esophagus to make a low-pressure valve) - PerOral endoscopic myotomy (**POEM)
- **ESD (endoscopic submucosal dissection)
- 1st line nowadays
- no Dor fundoplication done —> very often ***acid reflux
End-staged Achalasia:
5. ***Esophagectomy
- Esophagus is tortuous / sigmoidal —> food can stuck along way (even if LES released surgically)
Chicago classification of Achalasia
Achalasia:
- Failed relaxation of LES (IRP >= ULN)
AND
- Failed peristalsis of ***esophageal body
***Major disorders of peristalsis: Entities not seen in normal subjects
1. IRP (Integrated relaxation pressure): Pressure at LES in response to swallow
- If IRP >= ULN: Failed relaxation
AND
- Failed peristalsis
—> Achalasia
- If IRP >= ULN and not type 1-3 Achalasia:
- Look for other causes of obstruction: Mechanical obstruction - IRP normal
- Short DL: **Distal esophageal spasm
- High DCI: **Jackhammer esophagus (high amplitude abnormal contractions)
- Failed peristalsis: ***Absent contractility
***Minor disorders of peristalsis: Impaired clearance (also see in normal subjects)
- Ineffective motility (IEM)
- fragmented peristalsis
- Diffuse esophageal spasm (DES)
IRP normal, ***Short DL
- Almost simultaneous contraction of esophagus with Swallowing (不協調收縮)
Barium swallow / Endoscopy:
- ***Spiral appearance of Esophagus (“Corkscrew” deformity)
S/S:
- Dysphagia
- ***Chest pain
- Seldom significant weight loss
- Pills induced ulceration
- ***NSAIDs
- ***Tetracyclines
- KCl (Slow K)
- ***Alendronate (Bisphosphonate)
- Pharyngeal pouch / Zenker’s diverticulum
- False diverticulum
- A sac which can trap food
Etiology:
- Uncoordinated swallowing, Impaired relaxation, Spasm of the **cricopharyngeus muscle (UES)
—> ↑ pressure within distal pharynx
—> its wall herniates through point of least resistance (known as **Killian’s triangle, located superior to cricopharyngeus and inferior to thyropharyngeus)
S/S:
- **Halitosis
- **Regurgitation of food stored within sac
Treatment:
- **Resection of diverticulum + **Incise Cricopharyngeus (UES) (Myotomy: use muscle to patch the defect)
- Gastroesophageal reflux disease (GERD)
***Montreal definition: Reflux of gastric content leads to troublesome symptoms / complications
Etiology:
1. **Hiatus hernia —> Tortuosity + Mechanical obstruction + Volvulus of herniated stomach
- Type 1: Sliding
- Type 2: Rolling (GEJ still intraabdominal, not cause reflux, but more obstructive symptoms / even strangulation)
- Type 3: Mixed
2. **Lax LES
3. **Transient LES relaxation (TLESR)
4. **Poor esophageal clearance
5. Acid pockets
6. ***Increased intra-abdominal pressure (obesity, tight garment)
Clinical features:
1. Heartburn
- substernal discomfort
- radiation of pain towards mouth
- precipitated by meals and recumbency
- ameliorated with antacid
2. Regurgitation
Diagnosis:
1. **Chinese GERDQ (7 items)
2. **PPI test
3. ***Endoscopy
4. Manometry + 24 hour pH monitoring
Esophagitis:
- Graded by ***Los Angeles classification: Grade A-D
Complications:
- **Peptic stricture
- **Barrett’s esophagus (pre-malignant)
Treatment:
1. **Lifestyle modification
- Stop smoking, alcohol, chocolate, high fat diet, coffee, tea, cola, acid juices, peppermint, reduce size of meal
- Lose weight
- Avoid tight clothing
- Elevate head of bed
2. **Antacid
3. **H-2 antagonists
- Cimetidine, ranitidine, famotidine
4. Mucosa protectant
- Sucralfate
5. **PPI
- Omeprazole, lansoprazole, esomeprazole, rabeprazole
Indication for surgery:
1. **Compliance issue, preferred not to have life long medication / SE
- PPI responders (good prognostic factor)
2. **Refractory GERD
- PPI non-responders (10-30%)
3. **Regurgitation symptoms: usually not relieved by PPI (PPI only treat acid-related symptoms: esophagitis, heartburn but not reflux mechanism)
4. **Hiatal hernia (Anatomical defect to correct)
Surgery:
Complete vs Partial fundoplication
- **Nissen fundoplication (complete)
- **Toupet fundoplication (partial)
- ***Esophageal cancer
- High incidence in China / Asia (Hebei, Henan, ***Chewchow)
- ***Male predominant
- 10th mortality rank in HK
Symptoms (from SpC Interactive tutorial: Esophageal cancer):
1. **Dysphagia
2. **Regurgitation
3. **Loss of weight
4. **Retrosternal pain
5. Odynophagia
6. **Hoarseness of voice (RLN palsy)
7. **Cough + Chest infection (Aspiration, Tracheo-esophageal fistula)
Risk factors:
1. **Alcohol (Aldehyde dehydrogenase deficiency in Han Chinese —> Heterozygous flusher —> High risk of cancer)
2. **Smoking
3. **Salted fish, **pickled vegetables (Nitrosamine, Nitrite)
4. Infrequent citrus fruit
5. Infrequent green vegetables
6. ***Hot soup, beverage
(7. Micronutrient deficiencies (e.g. Selenium)
8. Mouldy food, fungi-toxins (e.g. Aflatoxin)
9. HPV
10. Genetics)
SCC:
- Above
- History of **H/N cancer —> **Field change effect (H/N region contact with same carcinogen as esophagus) —> screen for synchronous (within 6 months) / metachronous cancer (>=6 months from each other)
- **Caustic injury to esophagus —> chronic inflammation
- **History of radiotherapy
(- Achalasia
- Lye corrosive stricture
- **Paterson-Brown Kelly syndrome (aka Plummer-Vinson syndrome) (esophageal + laryngeal web, **Fe deficiency anaemia, dysphagia, glossitis, cheilosis —> female predominant, young —> ↑ risk of CA esophageal + hypopharynx)
- Tylosis (Howel-Evans syndrome))
Adenocarcinoma:
- **Barrett’s esophagus (Columnar epithelium migrate proximally to above GEJ)
- **Reflux symptoms
- **Overweight
- **History of radiotherapy
Adenocarcinoma of Esophagus
Epidemiology:
- ↑ Incidence —> ∵ ↑ GERD + Overweight
Pathogenesis:
Obesity
—> GERD
—> Barrett’s esophagus (***Metaplasia) (Screening)
—> Low grade dysplasia (Surveillance)
—> High grade dysplasia (Surveillance)
—> Cancer
Non-dysplastic Barrett: <1% malignant transformation per year
Diagnosis:
1. **Endoscopic
2. **Histological: Intestinal metaplasia (Goblet cells)
**Prague criteria:
- measure **Circumferential (C) + ***Maximum extent of metaplasia (M)
Treatment:
- Low grade dysplasia: Local ablative (Radiofrequency ablation, **Endoscopic mucosal resection (EMR))
- High grade dysplasia: **Endoscopic resection (distinguish between sampling error vs true invasive tumour)
Management of Esophageal cancer
Staging investigations:
1. **Endoscopy
2. **Endoscopic USG
3. **CT
4. **PET-CT
5. Pathological examination
Localised Tis / T1a (i.e. early):
- ***Endoscopic therapies (ESD, EMR, Ablative therapy)
—> if diffuse: may develop stricture after EMR —> may do upfront esophagectomy instead
T1b / T2N0:
- ***Upfront esophagectomy
T1b-T4a, N0-N+:
- **Neoadjuvant Chemotherapy / Neoadjuvant Chemoradiation
—> **Esophagectomy (Curative with R0 resection)
- if too frail for surgery —> Definitive Chemoradiotherapy —> ***Salvage surgery (for residual / recurrent disease)
Cervical esophageal tumour (close to larynx, vocal apparatus):
- **Pharyngo-laryngo-esophagectomy
or
- **Definitive chemoradiotherapy —> Laryngeal-preserving esophagectomy
T4b / M1 (i.e. Inoperable, Metastasis):
- **Chemotherapy, **Radiotherapy, Palliative (stenting to maintain patency of esophagus)
Esophagectomy techniques
Phase:
- 1 Phase (1 incision in abdomen): Esophagogastrectomy (longer jejunum anastomose with lower esophagus, when stomach have tumour and cannot be used as conduit)
- 2 Phase (Transhiatal, Lewis-Tanner / Ivor-Lewis (Transthoracic))
- 3 Phase (***Mckeown (Transthoracic))
Transthoracic vs Transhiatal:
- Transthoracic: collapse lungs for adequate view of esophagus
- Transhiatal: no need to collapse lungs, can maintain ventilation, but suboptimal view + poorer quality of LN dissection —> mediastinal part of esophagus dissected bluntly
Ivor-Lewis vs Mckeown:
- Ivor-Lewis: dissect esophagus in chest, **2 incisions, stomach pulled up to **chest for anastomosis
- Mckeown: dissect esophagus in chest, **3 incisions, stomach pulled up to **neck for anastomosis (for proximally located tumour)
Field of LN dissection:
- Phase II: Thorax + Abdomen
- Phase III: Thorax + Abdomen + Neck
Conduit:
- **Stomach (rely on Right Epiploic Arcade to supply whole stomach, Short gastric vessels cut, rely on submucosal plexus to diffuse blood from **Right Epiploic Arcade + **Right gastric artery)
- **Colon
- ***Jejunum (tumour only involve cervical esophagus —> no need gastric pull-up —> free jejunal flap instead)
Route:
- **Orthotopic (natural route of esophagus)
- **Retrosternal (conduit run behind sternum, used when suspected residual tumour at posterior mediastinum, adjuvant radiotherapy can then be used to clear residual tumour)
- ***Subcutaneous (in front of sternum)
Anastomosis:
- Stapled (Linear, Circular)
- Handsewn
Approach:
- Open
- VATS (Video assisted thoracoscopic surgery)
- Total MIE (Laparoscopy)
- Robotic (tackle narrow cavity e.g. lung apex for LN dissection)
Position:
- Supine
- Left lateral (tackle through right chest)
- Prone (lung fall anteriorly —> make room for tackling posterior mediastinum)
SpC Interactive tutorial: Benign esophageal diseases
Esophageal perforation: Boerhaave’s syndrome
***Causes:
1. Iatrogenic (endoscopy, dilatation, intubation)
2. Intrinsic (carcinoma, peptic esophagitis)
3. Traumatic (FBI, post surgical, caustic injury, blunt / penetrating trauma)
4. Spontaneous (Boerhaave’s syndrome / Emetogenic)
Boerhaave’s syndrome:
- ***Retching against a closed glottis (also laughing, childbirth, trauma, heavy lifting)
Classical triad:
1. **Vomiting
2. **Excruciating chest pain
3. ***Subcutaneous emphysema
Symptoms:
- Chest pain
- N+V / Haemetemesis
- SOB
Signs:
- Sepsis
- Surgical emphysema
- Hydropneumothorax
Investigation:
1. CXR
- **Hydropneumothorax
- **Mediastinal air
2. **Endoscopy
- Site and size of perforation
3. **Water-soluble contrast study (NO barium)
- Site and size of perforation
4. CT scan
- Collections, mediastinal air, effusion, pneumothorax
Treatment:
1. **Resuscitation + **Antibiotics
2. Conservative
- in stable patient with very localized leak - selective
- hole can heal itself
3. **Drainage (what kills is dirty stuff)
4. **Surgical repair (usually for early diagnosis)
- close if possible (sometimes tissue can be unhealthy / edematous —> high risk of anastomotic leak)
5. Esophagectomy (rarely done, ?cancer)
6. Endoscopic stenting
7. Outcome depends on timely diagnosis + treatment
