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Mis carcinoma Esophagus
Minimally invasive esophagectomy (MIE) is an evolving technique for treating esophageal cancer that offers advantages over traditional open esophagectomy. MIE uses small incisions and video-assisted thoracic surgery to mobilize the esophagus, allowing for less post-operative pain, quicker recovery times, and reduced pulmonary complications compared to open techniques. While short-term outcomes are improved with MIE, long-term oncological outcomes still need to be defined as surgery aims to completely remove the cancer while preserving quality of life. MIE represents a shift toward less invasive options for esophageal cancer treatment when surgery is required.
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Mis carcinoma Esophagus
- 1. Minimally Invasive Surgery for EsophagealCancer Dr Harsh Shah MS,FMAS,DNB,MCh(GI) GI & HPB Surgeon Kaizen Hospital, Ahmedabad
- 2. What is MinimallyInvasive Surgery ? • Procedure carried out by entering the body through the skin or through a body cavity or anatomical opening • Types: Laparoscopy Thoracoscopy NOTES • Advantages: Smaller incision, Less pain, rapid recovery Lesser inflammatory response (IL-6, IL-8)
- 3. Esophageal Surgery “The historyof oesophageal surgery is the tale of men repeatedly losing to a stronger adversary yet persisting in this unequal struggle until the nature of the problems became apparent and the war was won.” Professor R. G. Emslie (1988)
- 4. Evolution of esophagectomy •The first thoracic esophagectomy for cancer – Franz Torek 1913 • 1946- Ivor Lewis two staged approach (Rt thoracotomy and separate laparotomy) • 1976 - Mc Keown 3 stage operation • 1991- Dallemagne – Right thoracoscopy approach • 1994 – Cushieri Prone thoracoscopic esophagectomy
- 5. Epidemiology • 6th mostcommon cause of cancer death • SCC > Adeno carcinoma • SCC more common in Asia • Risk factors – Tobacco, Alcohol • CTRT followed by surgery is the standard of care
- 6. Signs & symptoms •Early stages do not produce physical symptoms • Once cancer has advanced most common signs & symptoms are: Dysphagia – 90% Anorexia & Weight loss – 75% Odynophagia – 50% Less frequent Coughing & hoarseness of voice Chest pain often radiating to back Frequent choking on food Regurgitation & undigested food Hiccups
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- 8. Upper GI endoscopy& biopsy
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- 10. Management Protocol • UGIE& Biopsy, CT Scan/PET-CT • ? Esophageal Stenting/Feeding Jejunostomy • Neo-adjuvant CT-RT (50.4 Gy radiation with platinum based chemotherapy) • Surgery – Transthoracic esophagectomy + Infracarinal lymph node dissection
- 11. Pre-op Preparation • ImproveNutritional status – • Preferably enteral nutrition • If complete dysphagia – Stent placement • Incentive spirometry • Stop smoking • Bronchodilators – if PFT shows obstructive airway disease • Improve oro-dental hygiene – Betadine gargles
- 12. Esophagectomy is acomplex surgery • Location Posterior mediastinum • Surrounded by vital structure Trachea & bronchi Aorta Azygous vein RLN Thoracic duct • High incidence of anastomotic leak Absence of serosal layer Mucosal retraction Patient factors
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- 14. Right side ofmediastinum Esophagus Trachea Azygous vein Thoracic duct
- 15. Left side ofmediastinum Thoracic duct Vagus nerve Descending thoracic aorta
- 16. Lymphatic drainage • Bi-directional spread • Submucosal lymphatics •Considerable interconnection among the three drainage regions
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- 19. Types of Esophagectomy •Subtotal Esophagectomy Mckeown’s (Three stage) Thorax, Abdomen, Neck Transhiatal (Two stage) Abdomen, Neck • Partial Esophagectomy Ivor-lewis (Two stage) Abdomen, Thorax
- 20. Traditional transthoracic Esophagectomy (Mc-Keown’s) •Thoracotomy Esophageal mobilization Infracarinal Lymph node dissection • Laparotomy Gastric conduit formation Celiac Lymph node dissection Pyloromyotomy Feeding Jejunostomy • Neck incision Esophago-gastric Anastomosis Identify & Preserve recurrent laryngeal nerve
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- 23. Cause of highrespiratory complications • Single lung ventilation • Inadequate lung expansion due to post-operative pain • Division of tracheo-bronchial nerves • Recurrent laryngeal nerve injury
- 24. Respiratory complications followingesophagectomy N Pneumonia % Reintubations % Ventilator Dependency % Bailey et al 2003 1777 21.4 16.2 21.8 Atkins et al 2004 379 15.8 6.1 4.7 Avendano et al 2002 61 32.8 19.7 19.7 Tandon et al 2001 168 17.8 NA 23.8
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- 26. Definitive CTRT • Cervicalesophageal cancer • 60Gy RT with platinum based chemotherapy • SCC responds better • Recurrence rate – 30-50% • Higher incidence of tracheo-esophageal fistula
- 27. Esophagectomy for cancer •Morbidity 25-80% • Mortality 5-12% • Respiratory 25%, • Cardiovascular 12%, • Anastomotic leak 16%
- 28. Choice of treatment Trans-thoracic Esophagectomy DefinitiveCTRT Transhiatal Esophagectomy
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- 33. Advantages of MIE •Smaller incision less post-op pain • Immediate extubation • Excellent visualization of anatomy • Reduced pulmonary complications • Reduced ICU stay • Less incidence of RLN palsy • Early ambulation, Rapid recovery, shorter hospital stay
- 34. Advantages of PronePosition • Dual lung ventilation Rapid induction of anesthesia Reduced incidence of post-op lung collapse • Ergonomically better • Permits solo-surgery • Blood collects in dependent part Does not obscure the surgical field
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- 37. Shift in selectionof treatment modality? Trans-thoracic Esophagectomy/ MIE Definitive CTRT Transhiatal Esophagectomy
- 38. BIG IS NOTALWAYS BETTER !! • Open thoracotomy • Prone MIE
- 39. Summary • Surgery isthe important component of the multimodality treatment of carcinoma esophagus • Surgery is complicated • Preop work up and patient optimization for the surgery is of utmost importance • Minimally invasive methods have significantly decreased the morbidity but long term oncological outcomes are yet to be defined.
- 40. Thank You Mission Gastrocare JetalpurRoad Vadodara