EpidemiologyCountry Incidence LinkUS 6 cases/100,000 men/year (Black>white).China (HenanProvince) 0.9% in the population Nitrosamine in the soil and older than 30 years of age contamination of foods by fungi (Geotrichum candidum) and yeast, which produce mutagensIndia, Pakistan, and Sri Lanka 9000 cases/year in 6 Chewing tobacco , smoking cancer registrySingapore Hot beverages, Chinese tobacco and wineSouth African Bantus and Zulus Nitrosamine in the soil and contamination of food by molds, especially the Fusarium speciesNormandy, Brittany Alcohol and smoking
Incidence Squamous AdenoNew cases per year 16980 12450Male-to-female ratio 3:1 7:1Black-to-white ratio 6:1 1:4Most common locations middle distalMajor risk factors smoking Barrett’s alcohol esophagusIn TMH 1200 pts /year2nd most common in men4th most common in femaleM0re than 180 Sx /yr
Etiology• Unknown• Hereditary & Genetics• Smoking and alcohol
• Dietary factors• *N-nitroso compounds (animal carcinogens) *Pickled vegetables and other food-products *Toxin-producing fungi *Betel nut chewing *Ingestion of very hot foods and beverages (such as tea)• Obesity• Work place exposure
Prevention and screening• Counseling : Avoid alcohol and tobacco• Endemic mass screening programmes• Screening high risk factor• Surveillance Programme Barrett’s esophagus without dysplasia endoscopy 3 yearly Low grade Dysplasia: every year High Grade Dysplasia every 6months 4 quadrant biopsy 2cm apart
Classificationmorphological histological Type I : polypoid Squamous carcinoma Type ll: ulcerated Adenocarcinoma Type lll: infiltrating ulcerated Mixed adenosquamous Type lV :diffuse undifferentiated Small cell carcinoma
Squamous cell carcinomaa) Upper thirds of esophagus-20%b) Middle thirds of esophagus-50%c) Lower thirds of esophagus-30%
Spread• Commonly spread by Lymphatic system (1) Local spread Trachea tracheoesophageal fistula Aorta Fatal hemorrhage Recurrent laryngeal nerve hoarseness of voice• (2) Lymphatic spread *Extensive submucosal lymphatic spread ( proximal line of resection should be 10cm proximal to the tumour). *Cervical ,mediastinal and coeliac LNs.• (3) Blood spread Lung, liver & brain.
Surgery• 1877- Czerny first surgeon to successfully resect a cervical esophageal cancer• Initially the anastomosis was done by bringing out the ends subcutaneously with external plastic tubes, skin tubes and flaps• 1933- Ohsawa first stomach reconstruction• 1946- Ivor Lewis two staged approach (rt thoracotomy and separate laparotomy)• 1976- Mc Keown 3 stage operation• 1982 & 1994 vagus nerve preservation• 1997 – laparoscopic total esophagectomy
Operable tumors 1) Tumors below the carina (tracheal bifurcation) Ivor Lewis operation(2 phases ) 1st phase :laparotomy & mobilization of stomach. 2nd phase Rt thoracotomy through the 5th intercostal space resection of the tumor .LNs and 10cm of the oesophagus above the tumor & GE anastomosis.
Tumors above the carina Mc Keown operation (3 phases ) 1st phase :laparotomy & mobilization ofstomach 2nd phase Rt thoracotomy through the5th intercostal space :esophagealmobilization 3rd phase: neck incision : theoesophagus & stomach are delivered to theneck where resection is done andanastomosis of the stomach & cervicaloesophagus is carried out.
Chemotherapy• Neoadjuvant• Two 4-day cycles,• 3 weeks apart• Cisplatin 80 mg/m2 by infusion over 4 h• fluorouracil 1000 mg/m2 daily by continuous infusion for 4 days. (MRC protocol)• Surgery performed two to four weeks after chemotherapy
Radiation therapyEBRT alone 64.8Gy / 33 - 36 fractionsExternal beam radiotherapy and brachytherapy EBRT• Dose : 60 Gy / 28 fractions with reducing fields. ILRT Boost : 5 - 8Gy / 2-3 fractions (HDR), one week apart or single fraction 20Gy low dose rate (LDR).
Concomitant chemo radiation• 50Gy / 25 fractions over 5 weeks,• Cisplatin 75 mg/m2IV Day 1 of weeks 1, 5, 8, and 11,• Fluorouracil, 1g/m2 per day by continuous infusion day1 – day 4 week 1, 5, 8, and 11. (RTOG regimen)
Palliative treatment• Inoperable Tumors ( 60% of the patients) * Local spread( e.g tracheoesophageal fistula,) * Distant spread• * Bad general condition• Options:- – Endoscopic Laser to core a channel through the tumor
Intubations– • Self expanding metal stents • Traction stents e.g. Celestine stent • Pulsion stents e.g. Soutter’ tube
– Radiotherapy for squamous cell ca– Dose : 3000cGy /10 fractions /2 weeks– Reduced field / boost : 2000cGy/10# / 2 weeks– ILRT alone or in combination with EBRT.– 5 - 8Gy/# in 2- 3 fractions, one week apart– Chemotherapy :5 FU + Cisplatin– 5Fu 1000mg/m2/day continuous IV infusion on day1- 5Cisplatin 100mg/m2 iv on day 1– Repeat cycles on 1,5, 8, 11 wks
Psychological preparationAssess level of anxietyAnswer the questions and concernsregarding surgeryAllow time and privacy to preparepsychologicallyProvide support and assistanceCultural aspect need to be consideredDischarge planning
Legal preparationInformed consent by surgeonNo sedation should be administeredDocumentation
Nutritional supportAims : promote wt gainInterventions– Assess wt , nutritional assessment– Sr Albumin , protein– Assessment of swallowing capacity– High calorie high protein diet in liquid and soft form– Enteral nutrition: NG feeds– Parentral nutrition– Hydration– Adjust diet according to existing problems- constipation/diarrhea
Prevent pulmonary complicationsPatients are not able to clear secretionsHead elevationStent placement and dilatation
Physical and physiological preparation• Cleaning of surgical site• Shaving• Personal hygiene• Oral care• Nutrition: liquid diet x 3 days• Monitor vital signs• Intake /output chart• Antibiotics and regular medications NPO night before No enema and laxatives can be allowed
Pain managementExplain to notify painPain medications will be prescribedNon invasive pain relieve techniques
Preoperative exercisesStop smokingChest physiotherapyIncentive spirometryFootball bladder exercisesCoughing exercisesDeep breathingSplintingGetting out of bed
Pre anesthetic work upAll investigations & corrections toCo morbiditiesECGPFTArterial blood gas2d echoMouth openingCheck listSend all equipments to OT
• Neurological Status• Assess neurological status every shift.• Any neurological change should be carefully watched and• Promptly reported
Pain Management Adequate pain control reduces the mortality and morbidity Asess the pain Initial pain management consist of morphine or bupivacaine given epidurally Patient-controlled analgesia with morphine, or a combination of both .Nothing by mouth for 5 to 7 days, intravenous or epidural pain medications are used.
Pain Management contd..Oral pain medications are started on the fifth or seventh postoperative day The main classes : opoids, nonsteroidal anti-inflammatory drugs, and local anesthetics.
Pulmonary Care Aggressive pulmonary toilet Pain control is paramount Patients are usually intubated after surgery monitor oxygenation closely (spo2) Suctioning Chest physiotherapy ,Nebulizers Coughing, deep breathing exercises, Incentive spirometer. Teach patients to splint their incision with a pillow. Early mobilization Monitor patients closely for fever
Chest tube care Assess the drainage every shift.Serosanguinous within a few hours.Not more than 100 to 200 ml/h on the first day.A sudden change in the color of chest tube : milky (chyleleak ) Check the chest tube site for drainage, Keep the chest tube dressing clean, dry, and intact.Keep the chest tube free of any kinks or dependentloops
Subcutaneous emphysema Palpate the surrounding area Due to an air leak from a pleural injury Additional suction or placement of a new chest tube New-onset may indicate a leak of the esophageal anastomosis. . Fever, tachycardia, and hypoxemia Esophageal leak can be confirmed by barium swallow Postoperative chest radiographs for pneumothorax and for placement of any chest tube. Monitor abrupt changes in oxygenation
HemodynamicsIntravenous maintenance fluid at a rate of 100 to 200 ml/h for the first12 to 16 hours. Patients may require fluid boluses in the immediate postoperativeperiod.Crystalloids or blood products may be usedInterstitial pulmonary edema.Malnutrition and low protein levels can complicate the situation.A delicate balance between adequate fluid replacement and fluidoverload. 30 ml/h of urine outputDetermination of body weightMeticulous skin care is necessary.
Nasogastric Tubes. Do not move, manipulate, or irrigate thenasogastric tube.Do not attempt to replace it. Monitor the tube for patency Assess the drainage for color andamount.
Gastrointestinal CareRestricted by mouth for 5 to 7 daysOral medications, are crushed and put down the nasogastric tube onthe second day ; they are never swallowed.Diligent mouth careA jejunostomy feeding tube is often placed during surgery and isused from the first post op day for feedingEarly enteral feeding helps in early healingJejunostomy site care
At 5 to 7 days check the anastomosis for leaks Eat 6 to 8 small frequent meals each day, Avoid very hot or cold beverages and spicy foods. Protein supplements, high-energy foods, or a soft dysphagia diet Sit upright, chew slowly, and eat more than 3 hours before bedtime assists in reducing reflux. Drink fluids between meals rather than with meals Dumping syndrome, may arise in patients who have had their vagus nerves divided. After vagotomy is related to unregulated gastric emptying Minimizing liquids with meals Consumption of frequent, small, low-carbohydrate meals Discharged with plans for supplemental tube feeding.
Incision CareKeep dressings clean, dry, and intact.Change dressing 2 to 3 times a daySaliva leak out through the cervical incision. Canbe managed by simple dressingLarge volumes (>250 ml every 8 hours),application of a wound drainage bagThe leak is allowed to seal on its own,Sealing could take several weeks.
Infection RiskCompromised nutritional status,They have invasive cathetersRisk of infection at the surgical sites.Meticulous wound and skin care,Hand washing,Avoidance of cross-contaminationChanging of invasive cathetersAntibioticsAdequate nutrition.
Prophylaxis of deep vein thrombosisHeparin s/c BDTED stockingsEarly ambulationLeg and ankle exercises
• Do’s Check surgical incision Maintain personal hygiene Incision site care Resume daily activities, work and sexual activities Drink fluid b/w meals Eat 3 hrs before bedtime Check wt
Contd… Take stool softeners Crush all medications Observe complications: tarry stool, progressive wt loss, diarrhea Keep follow up appointments
• Don’ts Avoid smoking (join stop smoking group) Avoid strenuous activity for 12 wks Avoid driving for 3 wks Avoid hot & cold beverages , spicy food Drink fluid in between meals
RehabilitationPatient must sleep in a head high positionGet adapted to small frequent mealsKeep a difference of 2-3 hrs betweenmeals and bed timeContinue spirometer for 3 monthsDonot carry weight more than 5 kgsResume daily activities