Surgery

1. NEOPLASMS OFNEOPLASMS OF
OESOPHAGUSOESOPHAGUS

2. CARCINOMA OESOPHAGUSCARCINOMA OESOPHAGUS
Common in China,S.africa &AsianCommon in China,S.africa &Asian
countries.countries.
66thth
most common cancer.most common cancer.
Less than 1% of all cancers.7% of all GILess than 1% of all cancers.7% of all GI
malignancies.malignancies.
Karnataka & Orissa.Karnataka & Orissa.
Advanced stages – Dysphagia – palliation.Advanced stages – Dysphagia – palliation.
Surgery – Rx of choice for early growthsSurgery – Rx of choice for early growths

3. AETIOLOGYAETIOLOGY
Diet- deficencies(vit A, C & Riboflavin)Diet- deficencies(vit A, C & Riboflavin)
Mycotoxin - common aftr 45 yrsMycotoxin - common aftr 45 yrs
Alcohol & tobacco –common in menAlcohol & tobacco –common in men
Fungal contamination of foodFungal contamination of food
Achalasia cardiaAchalasia cardia
Oesophageal websOesophageal webs
Barret”s oesophagusBarret”s oesophagus
Plummmer vinson”s sydromePlummmer vinson”s sydrome
Corrosive stricturesCorrosive strictures
TylosisTylosis
NitrosaminesNitrosamines

4. PATHOLOGYPATHOLOGY
Common in - Middle 3Common in - Middle 3rdrd
(50%)(50%)
Lower 3Lower 3rdrd
(33%)(33%)
Upper 3Upper 3rdrd
(17%)(17%)
Lower 3 cm- Adenoca common(Barrett”sLower 3 cm- Adenoca common(Barrett”s
columnar metaplasia)columnar metaplasia)
SCC – Commonest in india & AsiaSCC – Commonest in india & Asia

6. GROSS TYPESGROSS TYPES
Annular –(15%)Annular –(15%)
Ulcerative –(20%)Ulcerative –(20%)
Fungating-cauliflower like –(60%)Fungating-cauliflower like –(60%)
PolypoidPolypoid
Varicoid –diffuse submucosal typeVaricoid –diffuse submucosal type

7. SPREADSPREAD
DIRECT SPREADDIRECT SPREAD
LYMPHATICLYMPHATIC
BLOOD SPREADBLOOD SPREAD

8. CFCF
Recent onset of dysphagia(2/3Recent onset of dysphagia(2/3rdrd
lumenlumen
occlusion)occlusion)
RegurgitationRegurgitation
Anorexia , loss of weight & cachexiaAnorexia , loss of weight & cachexia
Pain – Substernal or in the abdomenPain – Substernal or in the abdomen
Liver secondaries, ascitisLiver secondaries, ascitis
Bronchopneomonia, melaenaBronchopneomonia, melaena
Features of broncho-oesophageal fistula in CAFeatures of broncho-oesophageal fistula in CA
upper 3upper 3rdrd
oesophagusoesophagus

9. Left supraclavicular lymphnodes may
be palpable
Hoarseness of voice
Hiccough
Backpain due to nodal
(paraoesophageal or coeliac) spread
M:f- 3:1

10. INVESTIGATIONSINVESTIGATIONS
Ba swallow-shouldering sign n irregularBa swallow-shouldering sign n irregular
filling defectsfilling defects
OesophagoscopyOesophagoscopy
Biopsy (confirmation)Biopsy (confirmation)
Chest X-ray(aspiration pneumonia)Chest X-ray(aspiration pneumonia)
BronchoscopyBronchoscopy
Oesophageal endosonographyOesophageal endosonography
CT scanCT scan

11. u/s abdomen
Endoscopic oesophageeal staining
Blood test
Laproscopy
PET scan
Video assisted thoracoscopic approach

12. TreatmentTreatment
Gastrostomy shud not b done as aGastrostomy shud not b done as a
palliative procedurepalliative procedure
For early growth without nodal spread-For early growth without nodal spread-
radical oesophagectomyradical oesophagectomy
If nodes+ -multimodal aproachIf nodes+ -multimodal aproach
used(curative resection,radiotherapy nused(curative resection,radiotherapy n
chemotherapy)chemotherapy)
Neoadjuvant therapy prior to surgNeoadjuvant therapy prior to surg

13. Advanced cases-palliation
Indications 4 curative treatment
 1.early growth when patient is fit
 2.when no involvemnt adj perioesophageal
structres or distant organs
Indications for palliative therapy
 1.Relieves pain
 2.Relieve dysphagia
 3.prevent bleeding
 4.prevent aspiration

14. STAGING OF CA OESOPHAGUSSTAGING OF CA OESOPHAGUS
T0: no primary trT0: no primary tr
Tis:CA insituTis:CA insitu
T1: Tr involving mucosaT1: Tr involving mucosa
T2: Tr involving muscularis propriaT2: Tr involving muscularis propria
T3: Tr with paraoesophageal spreadT3: Tr with paraoesophageal spread
T4: involvement of recurrent laryngealT4: involvement of recurrent laryngeal
nerve, phrenic nerve, sympatheticnerve, phrenic nerve, sympathetic
chain,azygos vein ; malignant effusionchain,azygos vein ; malignant effusion

15. No :No lymph nodes
N1: Mobile regional lymph nodes
M0: No distant metastasis
M1a: Upper thoracic oesophageal CA with spread
to necknodes or lower oesophageal CA with spread
to coeliac nodes
M1b: Upper TE CA with spread to other non
regional nodes or distant spread.Middle TE CA with
spread to necknodes or coeliac nodes or other npn
regional nodes.Lower TE CA with spread to other
nonregional nodes or distant spread.

16. Approaches for different level tumoursApproaches for different level tumours
Post cricoid tr(SCC)Post cricoid tr(SCC)
radiotherapyradiotherapy
pharynolaryngectomypharynolaryngectomy
Upper 3Upper 3rdrd
growth(SCC)growth(SCC)
radiotherapyradiotherapy
Mc Keown three phased oesophagectomyMc Keown three phased oesophagectomy
Middle 3Middle 3rdrd
growth(SCC) Ivorgrowth(SCC) Ivor
lewis operation palliativelewis operation palliative
radiotherayradiotheray

17. Lower 3rd
growth(SCC +Adenoca)
Partial oesophagogastrectomy
Transhiatal blind total oesophagectomy
Other approaches
Thoracoscopic – lap oesophagectomy
Radical oesophagectomy

18. POST OP MGMTPOST OP MGMT
Fluid & electrolyte mgmtFluid & electrolyte mgmt
Antibiotics& proper analgesiaAntibiotics& proper analgesia
Resp careResp care
Prevention of DVTPrevention of DVT
TPN only during initial postop periodTPN only during initial postop period
&early jejunostomy feeding for nutrition&early jejunostomy feeding for nutrition

19. PALLIATIVE PROCEDURESPALLIATIVE PROCEDURES
External or intraluminal RTExternal or intraluminal RT
Traction tubes like celestinTraction tubes like celestin
Pulsion tubes like selfexpandable metalPulsion tubes like selfexpandable metal
stentsstents
Endoscopic laserEndoscopic laser
ChemotherapyChemotherapy
Transhiatal oesophagectomy- orringerTranshiatal oesophagectomy- orringer

20. COMPLICATIONS OFCOMPLICATIONS OF
OESOPHAGECTOMYOESOPHAGECTOMY
5 – 10% Mortality5 – 10% Mortality
HgeHge
Resp infectionResp infection
SepticaemiaSepticaemia
ChylothoraxChylothorax
Anastomotic leakAnastomotic leak
HoarsenessHoarseness
Stricture frmnStricture frmn

21. Terminal events in CA oesophagusTerminal events in CA oesophagus
Cancer cachexiaCancer cachexia
Sepsis , mediastinitisSepsis , mediastinitis
ImmunosupressionImmunosupression
Malignant tracheo oesophageal fistulaMalignant tracheo oesophageal fistula
Erosion into major bld vessel - bleedingErosion into major bld vessel - bleeding

22. PROGNOSISPROGNOSIS
NOT GOOD –early spread , longitudinalNOT GOOD –early spread , longitudinal
lymphatics , aggresiveness , difflymphatics , aggresiveness , diff
approach ,late presentationapproach ,late presentation
Nodal involvement – bad prognosisNodal involvement – bad prognosis
5 yr survival rate- 10%5 yr survival rate- 10%

23. BENIGN TUMOURSBENIGN TUMOURS
RareRare
Grows by exapnsion .Never infiltrates orGrows by exapnsion .Never infiltrates or
spreads.spreads.
Usually in submucous planeUsually in submucous plane
Obstuction, regurgitation, aspiration,Obstuction, regurgitation, aspiration,
mediastinal compressionmediastinal compression
LEIOMYOMA COMMONEST (65%)LEIOMYOMA COMMONEST (65%)

24. Smooth , sessile , lobulated , firm ,grey white
whorled appearance
Multiple localised leiomyomas can occur
which can be enucleated independently
90% -in Lower 3rd
INVESTIATIONS
Ba swallow x-ray, oesophagoscopy,
endosonography , CTscan

25. TreatmentTreatment
Enucleation is the therapy of choiceEnucleation is the therapy of choice
Oesophageal ressection for large tumoursOesophageal ressection for large tumours