The esophagus is a hollow muscular tube that carries food from the throat to the stomach. Much of this passes through the chest, behind the trachea (windpipe). Tumours can occur anywhere along this track (in the neck, chest or abdomen). They can be either benign or malignant.
The malignant esophageal cancers can be of 2 types: squamous cell carcinoma or adenocarcinoma. Squamous cell carcinoma is related to smoking and alcohol. This is type that is common in Asians. The adenocarcinomas, on the other hand, are associated with longstanding damage from gastroesophageal reflux disease. This is the type that is common in the Western population.
The commonest symptom is progressive difficulty in swallowing. The patient feels food (and eventually fluids) getting stuck. This may eventually result in vomiting, pain and weight loss.
It is important to go for a diagnostic test if you have any of these symptoms. The best investigation is a gastroscopy. A long, thin and flexible telescope is passed into the esophagus all the way to the stomach and duodenum. Any suspicious growths can be biopsied.
Once an esophageal cancer is diagnosed we will arrange special tests to see if the cancer has spread. These tests may include a CT scan of the chest and abdomen, a bronchoscopy to evaluate the windpipe and airways, a bone scan, and an Endoscopic Ultrasound (EUS). The EUS procedure is similar to a gastroscopy, but a special ultrasound built into the tip of the scope allows us to see if the cancer has invaded the surrounding tissues.
This whole process of evaluation is called pre-op staging. Once we know the stage of the cancer we can plan the best treatment possible for the patient. If the cancer is resectable and has not spread, curative surgery is the best option. If the cancer has already spread to distant organs, we will try to palliate the patient’s symptoms by non-surgical means.
Surgery offers the best chance of cure. The main aim of surgery is to resect the tumour bearing esophagus with a good margin of tissue to obtain cancer clearance. The stomach is then reconstructed into a gastric tube to re-establish continuity with the remaining esophagus. Because the esophagus passes from the neck into the chest and abdomen, this is sometimes tricky. There are several operative approaches we can use and the preferred option depends on the location and size of the tumour as well as the general condition of the patient. Some of the approaches we prefer include:
The chest is opened up on the right side. The esophagus is resected together with a systematic removal of the surrounding lymph nodes as these may contain spread of the cancer cells. The abdomen is opened to resect the lymph nodes near the stomach. The stomach is re-fashioned into a tube, pulled up into the left neck and joined to the cut end of the healthy esophagus there. The lymph nodes in the neck are removed as well. This operation offers the best cancer clearance but the entire operation takes about 6 hours and may not be suitable for patients who have serious medical problems.
For cancers located in the mid and lower esophagus, it may not be necessary to extend the resection up to the neck. The gastric tube is formed through an abdominal incision and pulled up into the right chest after resection of the esophagus and surrounding lymph nodes.
The chest is not opened up at all. Instead, the resection of the esophagus is performed through the abdominal incision and left neck incision. Part of the operation is performed “blind” and lymph node clearance may not be very complete. However, this operation is quicker to perform and has less complications as the chest is not entered. It is therefore ideal for patients who have major co-existing medical problems or whose tumour is small and easily removed.
The chest is not opened up with a long incision. Instead, a telescope and fine, long instruments are inserted between the rib spaces to complete the thoracic part of the esophageal resection. Visualization is excellent using this approach and post op recovery seems to be faster.
Esophageal surgery carries a moderate to high risk depending on the general condition of the patient. The patient will need high dependency or intensive care observation for the first few days after surgery. Occasionally a ventilator is needed to help the patient breath. If all goes well the patient is re-introduced to fluids and soft diet 1 week after surgery.
The major risks of surgery include lung infection and other respiratory problems, cardiac complications and anastomotic leakage. This happens when the connection between the stomach tube and the esophagus fails to heal well (usually due to poor nutrition in a depleted patient). This can result in a prolonged hospitalization or even post-op mortality.
The patient will be able to eat normally after surgery, although in smaller portions. In the follow up care, we will pay close attention to nutritional problems. We may also need to schedule regular tests to detect recurrences of the cancer.
If surgery is not possible (due to distant spread of the cancer or if the patient is of high surgical risks), we can offer chemotherapy and radiotherapy. If the cancer responds to the treatment, we can often achieve good results. In some patients we give the chemotherapy and radiotherapy before surgery in order to shrink the tumour. This makes surgery easily and may confer a better chance of cure.
Patients with very advanced cancer can also be given palliative treatment to relieve the swallowing difficulties. Endoscopy can be used to core a passage through the tumour with laser, or a stent can be placed across the narrowed passage to keep the esophagus open.
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