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home - Oesophagus - Oesophageal Cancer - Surgical Treatment Written by Dr Sebastian Zeki
Knows the predisposing factors, presentation, diagnostic work-up and
staging

Knows the range of potential therapies (including palliative care), and
understand how the appropriate selection is made

Surgical Treatment

Ivor-Lewis transthoracic esophagectomyThis is indicated usually for GOJ tumours.Only one incision is required.Disadvantages include a high incidence of complications such as postoperative reflux and limitation of the proximal oesophageal margin by the aortic arch.The perioperative mortality rate is 4 %.Major respiratory or cardiovascular/thromboembolic complications occur in 17 and 7 %.Mediastinal leak occurs in 4%( ischaemic or anastomotic).The Technique involves either one continuous incision from the chest onto the abdomen or separate chest and abdominal incisions.The completed oesophageal replacement using the stomach connected to the esophagus high in the chest.The pylorus (muscle at the outlet of the stomach) has been cut to insure that the stomach empties adequately after the operation. Transhiatal oesophagectomy This involves an upper midline laparotomy and a left neck incision.The thoracic oesophagus is bluntly dissected through the diaphragm and via the neck incision, and a cervical anastomosis is then created most utilizing a gastric pull-up; thoracotomy is not required.Drawbacks of this approach include the inability to perform a full thoracic lymphadenectomy and lack of visualization of the midthoracic dissection.En-bloc resection of the mediastinal and upper abdominal lymph nodes is standard.There is a 5 year survival rate of 23 %.There is a perioperative mortality rate of 4 %.There is an anastomotic leak rate of 13 %.Atelectasis and pneumonia occur in 2 %.Intrathoracic hemorrhage, recurrent laryngeal nerve (RLN) paralysis, chylothorax, and tracheal laceration in <1 % each. Tri-incisional oesophagectomyA right posterolateral thoracotomy is performed and then laparotomy is carried out to obtain complete oesophageal dissection and en bloc resection with all mediastinal and upper abdominal lymph nodes and to mobilize the gastric conduit.A left neck incision and cervical anastomosis completes the operation.The three-incisional technique allows the surgeon to perform a complete two field (mediastinal and upper abdominal) lympha-enectomy under direct vision and a cervical oesophagogastric anastomosis.A left neck exposure is preferred for the esophagogastric anasto-mosis, as it avoids the recurrent laryngeal nerve (RLN). Cervical ProceduresThis involves removal of portions of the pharynx, the larynx, the thyroid gland, and portions of the proximal oesophagus.It requires cervical, abdominal and thoracic incisions and a permanent terminal tracheostomy.Radical neck dissections are usually carried out.Restoration of GI tract continuity can be accomplished with a gastric pull-up and anastomosis to the pharynx.For tumours confined to the proximal portion of the cervical oesophagus, with a sufficient distal resection margin, a free jejunal interposition graft or a deltopectoral or pectoralis major myocutaneous flap are alternative reconstructive options to restore GI tract continuity.Graft necrosis, fistula formation, and later graft strictures are specific problems.When compared with gastric pull-up procedures, graft survival and leakage rates are similar.Although surgery is considered for selected patients with earlier stage disease, radiation combined with chemotherapy is preferred over surgery for patients with locally advanced disease, since survival appears to be the comparable. Thoracic Complications of surgery: Chest infection. Chylothorax. Recurrent laryngeal nerve palsy. Benign anastomotic stricture. Anastomotic leakage (early-72 hours/late-up to 2 weeks due to ischaemia). Surgery for Oesophageal Cancer Written by Dr Sebastian Zeki

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