Mis carcinoma Esophagus
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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 Esophageal Cancer Dr Harsh Shah MS,FMAS,DNB,MCh(GI) GI & HPB Surgeon Kaizen Hospital, Ahmedabad
- 2. What is Minimally Invasive 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 history of 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 most common 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
- 8. Upper GI endoscopy & biopsy
- 9. CECT Chest
- 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 • Improve Nutritional 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 a complex 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
- 14. Right side of mediastinum Esophagus Trachea Azygous vein Thoracic duct
- 15. Left side of mediastinum Thoracic duct Vagus nerve Descending thoracic aorta
- 16. Lymphatic drainage • Bi-directional spread • Submucosal lymphatics • Considerable interconnection among the three drainage regions
- 18. TNM STAGING
- 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
- 23. Cause of high respiratory complications • Single lung ventilation • Inadequate lung expansion due to post-operative pain • Division of tracheo-bronchial nerves • Recurrent laryngeal nerve injury
- 24. Respiratory complications following esophagectomy 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
- 26. Definitive CTRT • Cervical esophageal 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 Definitive CTRT Transhiatal Esophagectomy
- 29. Prone MIE
- 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 Prone Position • 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
- 35. Surgical Outcome
- 37. Shift in selection of treatment modality? Trans-thoracic Esophagectomy/ MIE Definitive CTRT Transhiatal Esophagectomy
- 38. BIG IS NOT ALWAYS BETTER !! • Open thoracotomy • Prone MIE
- 39. Summary • Surgery is the 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 Jetalpur Road Vadodara