Esophagus has rich submucosal network of lymphatics which makes longitudinal spread of tumor prevalent.There is propensity for early spread and widespread nodal metastasis. Adequate proximal (10 cm) and distal resection margin must be achieved.

1. Surgical management of
Carcinoma Esophagus
Dr Neelam Ahirwar
DNB, Surgical Oncology

2. OUTLINE
• Endoscopic Management
• Surgical steps
• Approaches - THE vs TTE
• Minimally Invasive Esophagectomy (MIE)
• 2 Field vs 3 Field Lymphadenectomy
• Reconstruction
• Complications

3. INTRODUCTION
• Rich submucosal network of lymphatics which makes longitudinal spread of tumor prevalent.
• Adequate proximal (10 cm) and distal resection margin must be achieved.
• Propensity for early spread and widespread nodal metastasis.
• Lymph node metastases are found in less than 5% of intramucosal tumors
• Tumors infiltrating submucosa- 30-50% has metastatic nodes
• Commonly- mediastinum, perigastric region, celiac trifurcation and neck
• Data from Japan- cervical nodes seen in 60, 20, 12.5% in upper,middle and lower primary respectively

4. • Sometimes even 30% positive cervical nodes in lower esophagus primary (selected US and European
centres)
• Cervical nodes- mainly below omohyoid muscle, around paratracheal/paraesophageal area as a
continuum of recurrent laryngeal nerve nodal package from superior mediastinum.
• En bloc resection – removing the primary tumor with enveloping sheath of pericardium, thoracic duct,
azygous vein, intercostal vessels,bilateral pleura overlying the tumor, surrounding cuff of crura (if
abutment present)

5. • Localized disease : 22 percent of all cases
• Goal of surgical management is curative.
• Surgical resection is the traditional mainstay of multidisciplinary therapy
for patients with localized disease
• The clinical spectrum of esophageal cancer has changed over the last
few decades, with an increase in incidence of adenocarcinoma and a
decrease of squamous cell carcinoma
• Surgical management is independent of histology.

7. Management of Early
Esophageal carcinoma

8. ENDOSCOPIC THERAPY
• Therapeutic
• staging
• Endoscopic resection
• Ablation methods
(RFA,PDT,cryotherapy)
Indications
• Tis and T1a (mucosal),T1b(sm1)
• <2cm Well or moderately
differentiated scc or adeno
• Elderly with multiple comorbidities
• Patient preference

9. • T1b stage is divided into the upper one third of the submucosa (sm1),
middle one third (sm2) or lower one third (sm3).
• This classification is also used by the Japanese society for Esophageal
Diseases
• The depth of tumor invasion has been shown to correlate with the rate of
lymph node (LN) involvement in esophageal carcinoma

11. HIGH RISK FACTORS FOR LYMPH
NODE METASTASIS
• Depth of invasion
• T1b Morphology
• Lymphatic permeation
• Poor histological differentiation
• Tumor size >2cm Infiltrative growth pattern
Takubo et al. Histopathology 2007;51:733-742

12. Endoscopic Resection

13. Endoscopic Mucosal Resection (EMR) As
Intermediate Staging Strategy
• accurate depth of invasion
• The pathology result from the endoscopic resection (particularly
the presence or absence of LVI) can be used to guide the final
decision as to whether endoscopic therapy alone is sufficient or if
surgery should be recommended

14. EMR
• Haemorrahge,Stricture
• PPI
• Surveillance

15. Photodynamic therapy(PDT)

16. Photodynamic therapy (PDT)
• uses a photosensitizing drug that is administered to the patient,
localized to a tumor, and then activated with a laser to induce a
photochemical reaction to destroy the cell.
• PDT using porfimer sodium followed by excimer dye laser
irradiation is approved as a curative treatment for superficial
esophageal cancer in Japan

17. • no evidence from clinical trials.
• In this systematic review, surgical therapies showed superiority for survival, and
endoscopic therapies showed superiority in the control of mortality related to
cancer with a high rate of disease recurrence; also, for the comorbidity and the
mortality associated with the procedure, endoscopy is superior.
• Prospective, controlled trials with large sample sizes are necessary to confirm
the results of the current analysis

18. • The survival rates after 3 and 5 years were not similar and showed
superiority in the surgical therapies over time
• The difference in esophageal neoplasia–related death between the two
treatments was significant
• Although the recurrence rate is higher than the endoscopic therapies, as
demonstrated by the analysis of the 5-year disease-free survivals,
apparently disease control can be achieved with monitoring, identifcation,
and effective treatment of these recurrences.

19. ENDOSCOPIC RESECTION VS
ESOPHAGECTOMY
• Equivalent long term outcome in HGD and intramucosal carcinoma
• Lower morbidity(0% vs30%)
• Higher recurrence rate 18% at median follow of 43mth (Mayo clinic)
• Majority can be managed by repeat endoscopic treatment. Similar
long term complete response rate(98% vs 100%)
• Similar OS and DFS at5yrs.

20. Esophagectomy

21. Esophagectomy as first line of therapy
• cT1N0M0 lesions
• cT2N0M0 lesions are candidates in many medical centers
Esophagectomy following NACT/NACRT
• Patients with thoracic esophageal or EGJ tumors and full-thickness (T3)
involvement of the esophagus with/without nodal disease.
• cT4a disease with invasion of local structures (pericardium, pleura, and/or
diaphragm only) that can be resected en bloc, and who are without evidence of
metastatic disease to other organs

22. Indicators of unresectability —
• Metastatic disease
• Extra-regional LN spread (eg, paraaortic or mesenteric lymphadenopathy).
-The regional lymph nodes for all locations in the esophagus, including the
cervical and EGJ, extend from the periesophageal cervical nodes to celiac nodes.
-Celiac nodal metastases and mediastinal/supraclavicular nodes are scored as
regional nodal disease TNM staging system, regardless of the primary tumor
location.
-Number rather than location of involved LN determines the N stage

23. OPERATIVE
PROCEDURES

24. CERVICAL ESOPHAGEAL CANCER RESECTION
• CRT : Primary modality
• Surgical resection : Patients who fail CRT, or who opt for a surgical resection.
• Resection usually requires removal of portions of the pharynx, the larynx, the
thyroid gland, and portions of the proximal esophagus.
• Single stage, three-phase operation requires cervical, abdominal, and thoracic
incisions
• Permanent terminal tracheostomy.
• Bilateral radical neck dissections are generally performed
• Restoration of GIT continuity with a gastric pull-up and anastomosis to the
pharynx.
• Free jejunal interposition graft or a deltopectoral or pectoralis major
myocutaneous flap are alternative reconstructive options.

25. Thoracic Esophageal cancer
• middle or lower third esophageal carcinoma (except GEJ cancers),
generally requires total esophagectomy
• In selected superficial or early invasive esophageal cancer arising distally in
the setting of BE, a more limited resection can be performed
Choice of surgical approach depends upon many factors:
1. Tumor location, length, submucosal extension, and adherence to
surrounding structures
2. The type or extent of lymphadenectomy desired
3. The conduit to be used to restore GIT
4. Postoperative bile reflux , The preference of the surgeon

26. • MCKEOWN TRI-INCISIONAL ESOPHAGECTOMY
• IVOR-LEWIS TRANSTHORACIC ESOPHAGECTOMY
• TRANSHIATAL ESOPHAGECTOMY(THE)

27. 1) TRI-INCISIONAL ESOPHAGECTOMY-
MCKEOWN
• Combines the THE and TTE approaches (MIS can be performed)
• Transthoracic total esophagectomy with a thoracic
lymphadenectomy and cervical anastomosis
• Allows a complete 2-field (mediastinal and upper abdominal)
lymphadenectomy under direct vision.

28. ADVANTAGES OF NECK ANASTOMOSIS
• Easier management of a possible leak
• Lower reflux
• More extensive proximal resection margin
• Location outside of radiation ports if administered preoperatively.

29. 1. Thoracotomy
A right posterolateral thoracotomy or a thoracoscopy is performed to assess
resectability and exclude local invasion of contiguous structures
2. Laparotomy
Metastatic disease is excluded, and the stomach is mobilized with construction of
conduit
3. Neck incision
Left neck exposure preferred
Left RLN recurs lower (around the aortic arch) than the right RLN, which recurs
around the subclavian artery and is therefore more likely to be injured from a right
neck approach.

30. 2) IVOR-LEWIS TRANSTHORACIC ESOPHAGECTOMY
• Lower third of the esophagus
• Not the optimal approach for cancers located in the middle third because
of the limited proximal margin that can be achieved
• Combines a laparotomy with a right thoracotomy and an intrathoracic
anastomosis
• Direct visualization of the thoracic esophagus & allows a full thoracic
lymphadenectomy
• Minimally invasive Ivor-Lewis approach to a thoracotomy.

31. DISADVANTAGES- IVOR LEWIS
• Limited length of proximal esophagus that can be resected to
achieve a R0
• Intrathoracic anastomosis
• 3 to 20 percent risk of severe bile reflux
• Higher morbidity (64%) and mortality associated with leak
• With current technique, mortality rates are substantially lower

32. TRANSHIATAL
ESOPHAGECTOMY(THE)
• Distal esophagus and EGJ cancers.
• Upper midline laparotomy incision and a left neck incision.
• Blunt dissection of thoracic esophagus.
• Cervical anastomosis with a gastric pull-up.
• Disadvantages: Limited thoracic lymphadenectomy and blind
midthoracic dissection

33. Operative Steps

34. T

35. Technique (Transthoracic approach)
• Inferior pulmonary ligament is divided using electrocautery, and the lung is
retracted anteriorly
• Dissection of the esophagus begins at a point away from tumor and any
associated scarring, and the esophagus is encircled with a Penrose drain
• Traction on the Penrose drain allows for cautery dissection encompassing all
adjacent nodes
• Arterial branches directly off the aorta are clipped or ligated
• The azygos vein is typically divided

37. • At this level, the vagus nerves are identified
• Dissection cranial to this level involves the vagus nerves; the vagus nerves
are peeled off and away from the esophagus to avoid injury to the
recurrent vagus branches
• Dissection between the trachea and esophagus must be done with care
and with low cautery dissection to avoid injury to the membranous trachea.
Much of the dissection high in the chest can be done bluntly)
• The cranial aspect of the dissection is complete when one’s finger’s reach
easily above the frst rib.

39. • No effort is made to resect the thoracic duct, although it is sometimes injured.
• often, injury to the thoracic duct is evident when slightly cloudy or crystallized
fluid is seen pooling in the region of the duct. If an injury to the duct is seen, it
should be closed with a fine suture such as 5-0 Prolene
• Mass ligature of the duct, as it enters the chest, is then performed by
encompassing all tissue between the spine and aorta

41. Mediastinal Lymph node dissection

44. • The careful palpation of the liver and inspection of the serosal surfaces for
tumor implants
• Palpation of the GE junction and proximal stomach should be performed to
rule out gastric spread of tumor.
• The left lobe of the liver is mobilized and retracted to the right.
• The gastroepiploic artery is identifed and palpated
• Staying at least 2 cm away from the gastroepiploic artery, the lesser sac is
entered. Dissection continues cranially on the stomach along the greater
curvature
• Dissection may be performed by dividing tissue and ligating with 2-0 silk ties
or by using an ultrasonic scalpel.

46. • The stomach is retracted medially and the omentum laterally. Te artery itself
should not be grasped used for retraction.
• The gastroepiploic arcade ends near the point where the short gastric
arteries begin
• The gastrohepatic ligament is divided with cautery up to the GE junction
• The stomach is lifted anteriorly, and thin adhesions between the stomach
and pancreas are divided with cautery.
• The left gastric vessels are approached from behind the stomach
• The vessels are skeletonized, and lymph nodes are swept up onto the
specimen.
• The duodenum is then mobilized using a Kocher maneuver, bringing it to the
midline

47. • A pyloromyotomy or
pyloroplasty may be performed
with equivalent efficacy in
aiding gastric emptying.
• If a pyloroplasty is performed, it
is best to close it in a single
layer with interrupted (3-0 silk)
sutures

48. ROLE OF PYLOROPLASTY OR PYLOROMYOTOMY

49. • A neck incision is then made 6 cm in length along the anterior border of the
left sternocleidomastoid muscle starting at the sternal notch
• Deep to the platysma, dissection proceeds medial to the
sternocleidomastoid muscle and carotid sheath and lateral to the thyroid
• The omohyoid can be divided with cautery
• Blunt dissection is then used to approach the vertebral bodies
• Lying along the vertebral body, the Penrose drain is grasped and brought
out into the neck wound with the encircled esophagus

51. RECURRENT LARYNGEAL NERVE IDENTIFICATION
• Injury can occur during cervical or upper thoracic dissection.
• Incidence: 2-17 %
• More common when a cervical approach is utilized.
Principles
Precise knowledge of cervical esophageal anatomy.
Plane of dissection should be as close as possible to the esophagus
Avoidance of metal or rigid retractors along the TE groove.
Orringer MB, et al. Ann Surg. 2007

52. • Proximally, the esophagus can be gently mobilized
• The nasogastric tube is removed, and the esophagus is divided with a GIA
75-mm stapler
• A 2 silk suture is attached to the proximal margin, and the specimen is
drawn out into the abdomen
• The cervical end of this tie is fastened to a clamp.

57. HAND-SEWN VERSUS STAPLED
ANASTOMOSIS

58. CERVICAL VERSUS THORACIC
ANASTOMOSIS
• Equally safe when performed using standardized techniques.
• At present, the choice of anastomotic location remains clinician
dependent.
• A cervical anastomosis has a higher leak rate and risk of injury to
the RLN.
• However, the anatomic confines of the neck and thoracic inlet limit
surrounding tissue contamination and, thus, limit morbidity.

59. • 4 clinical trials (267 patients) : 132 cervical anastomosis vs
thoracic anastomosis
• Cervical anastomosis were associated with higher rate of
anastomotic leak (18 versus 4 %). • Significantly higher rate of RLN
injury (OR 7.14, 95% CI 1.75-29.14) • No difference in rate of
pulmonary complications, perioperative mortality, benign stricture
formation, or tumor recurrence at the anastomotic site.

60. THE

63. conduits

64. The stomach is the preferred organ for esophageal replacement because of
its
1.Blood supply
2.The resistance of these vessels to atherosclerotic disease
3.The need for a single anastomosis
4.The ability of the stomach to reach the neck without diffculty.
Contraindications
Prior gastric surgery
Scarring from peptic ulcer disease
Involvement with tumor.

66. The left colon is preferred over the right colon for several reasons.
• Its diameter more closely resembles that of the esophagus
• Its vascular supply has less variation
• Greater length can be obtained.
• Unfortunately, atherosclerotic disease most commonly affects the inferior
mesenteric artery,and the left colon is often more affected by diverticular
disease than the right.

67. JEJUNUM
• Jejunal interposition may be applied as a free graft, pedicled graft,
or Roux-en-Y replacement.
• Jejunum is often the third choice (after stomach and colon) for
esophageal replacement, because it cannot replace the entire
esophagus to the neck, but can be used to replace a portion of the
distal or proximal esophagus.
• Free jejunal grafts are used in limited reconstructions of the cervical
esophagus.

68. GEJ CANCER
Surgical management is
standard of care includes either
an esophagectomy with partial or
extended gastrectomy, with/out
thoracotomy.

69. Principles:
R0 resection,
4-cm (distal) gastric margin, 5-cm esophageal margin, and
Resection of at least 15 nodes in basins appropriate for the primary
tumor
Solely transabdominal approach without thoracoabdominal incision or
THE is not acceptable for tumors that involve the distal esophagus.
Siewert JR, et al. Chirurg 1987

70. • Left thoracoabdominal incision
(single incision)
• Gastric pull-up and an
esophagogastric anastomosis in
the left chest .
• Most useful for tumors involving
the GEJ.
• Disadvantages include a high
incidence of complications such
as postoperative reflux and
limitation of the proximal
esophageal margin by the aortic
arch

71. CIRCUMFERENTIAL RESECTION
MARGIN
• Unclear prognostic role till recently •
• The College of American Pathologists (CAP) defines a positive CRM as the presence of
esophageal cancer at the resection margin.
• The United Kingdom Royal College of Pathologists (RCP) defines a positive CRM as the
presence of esophageal cancer within 1 mm of the resection margin
• CAP criteria differentiate a higher-risk group of patients with resectable esophageal cancer
than the RCP criteria.
• Meta- analysis (14 cohort studies including 3566 patients) 5 yr mortality rates were higher for
patients with a + CRM
Chan DS, et al. Br J Surg. 2013

72. MORBIDITY AND MORTALITY
• The overall incidence of postoperative complications varies widely between 20
and 80 percent
• Includes systemic complications (eg, pneumonia, myocardial infarction) and
complications specific to the surgical procedure (eg, anastomotic leaks, recurrent
laryngeal nerve injury)
• Pulmonary complications : mc (16 – 67%)
• Anastomotic leak is the most dreaded (0-40%)
• The overall in-hospital mortality rates range from 0 to 22 percent.
• The overall 30-day mortality rates (excluding in-hospital deaths) is <1 to 6
percent.

73. TAKE HOME MESSAGE
• T1aN0, M0 with Favourable factors- Endoscopic Resection
• T1b,T2N0 MO- Upfront Radical Esophgectomy
• T3,T4 No or Any T N+- Cross Trial
• Transthoracic Mckeowen approach with standard 2 field
lymphadenctomy is ideal for mid and distal esophageal carcinoma
• Transthoracic Mckeowen with 3 field lymphadenctomy in Upper
esophagus tumours.

74. • A TTE is the mainstay of treatment for all tumors of the esophagus and
GEJ as it allows probably the best chance for complete resection, optimal
lymph node dissection and improved survival.
• In case of bulky tumor alongside the airway before or after neoadjuvant
treatment, a hybrid resection using a right thoracotomy, laparoscopy and
cervical anastomosis will be performed.
• This approach has the potential to limit complications as shown by the
MIRO-trial

75. • In the case of a proximal tumor or in case of lymph node
involvement in the cervical region (prior to neoadjuvant treatment or
during surgery), a 3-field lymph node dissection is deemed
mandatory

76. • More tailored resection and extent of lymphadenectomy to patients
with extensive co- morbidities, limited cardio-respiratory function or
other particular situation

77. •Thanks ( to be contd)