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Surgical anatomy
• Muscular tube 25 cm long
• Extent – cricopharyngeal sphincter to
cardia of the stomach
• 2 cm esophagus lies below the diaphragm
• Three constrictions
– Cricopharyngeal -15cm from incisor
– Aorta – 25 cm from incisor
– Left bronchus – 25 cm from incisor
– Diphragmatic and sphinctric constriction –
40cm from the incisor
Esophagoscopy
• Two types
– Fibre-optic
• Commonly used
• Used under light sedation
• Reduced chances of
perforation
– Rigid (done after barium
swallow)
• Not used commonly
• Needs anaesthesia
• Used for removing foreign
bodies
Esophageal Carcinoma
Introduction
• the seventh leading cause of cancer death worldwide.
• Common in areas of northern Iran, some areas of
southern Russia, and northern China.
• Squamous cell carcinoma is common but recently the
cases of adenocarcinoma are increasing
• Male more than female.
• sixth and seventh decades of life.
(probably no other carcinoma causes greater misery to
the patient due to development of inability to swallow
even fluids)
pathology
• Macroscopically three types
1 An annular stenosing lesion usually
found at the cardia
2. An epitheliomatous ulcer with raised
everted edges
3. A fungating cauliflower like friable mass
Spread of the cancer
• Direct .the main method of spread and
most important to the surgeon. it is both
longitudal and transverse in direction and
erodes the muscular wall
• Lymphatic .
• Bloodstream metastasis to liver are fairly
common and bone secondaries can also
occur
Etiology
• Squamous
– cigarette smoking and chronic alcohol exposure are the most
common etiological factors for squamous cell carcinoma.
– Chronic ingestion of hot liquids or foods
– Vitamin or nutritional deficiencies
– Poor oral hygiene
– Exposure to nitrosamines in the environment or food
– Certain medical conditions (e.g., Plummer-Vinson syndrome)
and caustic injury to the esophagus
– Human papilloma virus infection
• Adenocarcinoma
– GERD is the most common predisposing factor for
adenocarcinoma of the esophagus
– Barrett's esophagus
Clinical features
• Progressive dysphagia initially experienced for solids, but
eventually it progresses to include liquids
• Only 40 % patient report in within 3 months
• feeling that food is sticking on its way down to the stomach
• Weight loss is the second most common symptom
• Pain or discomfort can be felt in the epigastric or retrosternal area.
• Hoarseness caused by invasion of the recurrent laryngeal nerve
• Respiratory symptoms can be caused by aspiration of undigested
food or by direct invasion of the tracheobronchial tree by the tumor.
• the regurgitated material is alkaline mixed with saliva and possibly
streaked with blood
• Pain if it occur is usually a late manifestation (but is not a
contraindication to an exploratory operation)
Diagnosis
• Medical
• Surgery
• Radiotherapy
Surgery
• Esophagectomy is the treatment of choice
for esophageal cancer.
– Transhiatal esophagectomy
– Transthoracic esophagectomy
– Ivor-Lewis 2 stage and 3 stage surgery
• Contraindications
– metastatic disease,
– tumor invasion of nearby structures
– severe cardiovascular or pulmonary disease.
complication
• fistula of esophageal anastomosis
Radiation Therapy
• Palliative
• neoadjuvant therapy
• adjuvant therapy
• Each treatment lasts a few minutes and treatment is
usually given 5 days per week, for 6 weeks.
• Side effects include the following:
– Dental cavities
– Difficulty swallowing
– Dry, sore mouth and throat
– Fatigue
– Loss of appetite
– Reddening of the skin
– Swelling of the mouth and gums
Chemotherapy
• Chemotherapy is not used as a primary
treatment for esophageal cancer.
• Commonly cisplatin, 5-FU and paclitaxel
based combination is used
• Common side effects include the following:
– Diarrhea
– Fatigue
– Hair loss
– Loss of appetite
– Mouth and lip sores
– Nausea and vomiting
– Skin rash and itching
Stage wise Therapy
• Stage 0: Surgery is the best therapy
• Stage I: surgery.
• Stage II and III:
– surgery
– chemoradiation followed by surgery.
• Stage IV: Palliative therapies
– radiation therapy,
– chemotherapy,
– Bypass- stenting, laser therapy, surgical.
Prognosis