Esophagus is the food pipe. It starts just behind the voice box and connects throat to stomach in the abdomen. Its approximately 25 cms long. Esophagus travels the neck , chest and a small distance in the abdomen before ending in stomach.
Cancer of the esophagus is of two major types
(a) Squamous cell carcinoma
The management of the cancer of the esophagus is based on the stage of the cancer. Early cancers that are detected by screening programs ( cancers confined to mucosa) can be managed by endoscopic methods like endoscopic mucosal resection(EMR), endoscopic submucosal dissection ( ESD).
However, in India most of the cancers are not detected at this stage. The cancers that we commonly encounter are at a slightly advanced stage ( T2-T3, N+). Surgery is the best option of such cancers. Majority of these cancers require chemotherapy or combination of chemotherapy and radiation.
The purpose of such treatment is to shrink the tumor ( down stage ) so that cancer cells that are not visible on PET/CT scan or to naked eye during surgery are not left behind. Chemotherapy administered also attacks the cancer cells that may have reached the blood stream.
Surgery of the esophagus is based on the location of the tumor.
Esophagus is divided into three portions.
(a) The part traveling the neck ( cervical esophagus)
(b) Part travelling the chest cavity ( thoracic esophagus)
(c) part in the abdomen
The thoracic part of esophagus is further subdivided into upper,mid and lower thoracic parts.
Cancer of upper and mid thoracic esophagus :
For upper and mid thoracic esophageal cancers the ideal surgical treatment is complete esophagectomy (total esophagectomy). In this procedure almost the entire length of the esophagus is removed ( only a small segment of esophagus at its origin in the neck is left behind) along with a portion of stomach.
The remaining stomach is converted into a tube to replace the esophagus. Since the esophagus travels three regions ( neck, chest and abdomen) surgery needs to be carried out in all the three fields.
The first part of the surgery is carried out in the chest. This can be done with open surgery or with thoracoscopic or robotic surgery. The disadvantage of open surgery is that large surgical incisions in the chest cause lot of pain and compromise breathing. Hence we always prefer to perform this part of the surgery with the help of thoracoscopy or robotic surgery.
In this part the esophagus is dissected away from the surrounding vital structures like aorta, trachea and brochii. The small blood vessels supplying the esophagus are also divided. We usually prefer to divided the azygous vein as this step helps in the lymph node dissection later. Sometimes in advanced cancers thoracic duct may have to be ligated. Once the mobilization of the esophagus is complete, mediastinal lymph node dissection is carried out to remove all the affected nodes in the chest.
After the thoracic part the patient position is changed and patient is put in supine position. This part of the surgery consists of dissecting and mobilizing the abdominal part of the esophagus along with the stomach. The blood supply to the stomach is by 4 major arteries. 2 of these arteries are divided to mobilize the stomach. Surrounding nodes are also removed en bloc. This part of the surgery also can be carried out with open surgery or laparoscopy or robotic surgery. We prefer to use laparoscopy to carry out this part.
After this a neck incision is taken and esophagus is mobilized in the neck as well and it is divided in the neck and specimen is brought out of from a small abdominal incision. The lower division takes place now outside. This is carried out with the help of surgical staplers. This step serves two purposes. It converts the remaining portion of the stomach into a tube( 4-5cm wide) and removes the tumor containing specimen. The specimen is removed and sent for frozen section analysis.
The stomach tube thus prepared is tunneled from the abdomen through chest cavity into the neck. In the neck this tube is joined with the remnant of the esophagus. We prefer to use hand sewn technique to carry out this joining( anastomosis) but it can also be performed with the help of staplers.
Finally a feding jejunostomy is performed. This means a small tube is passed into the small intestine and brought out through the abdomen wall onto the skin. This tube is used for feeding the patient during the post operative recovery.
Cancer of the lower thoracic esophagus and gastroesophageal junction:
In the cancers affecting the lower thoracic esophagus and junction of stomach and esophagus there are two surgical options.
(1) Total esophagectomy
(2) Partial esophago gastrectomy.
Both these surgeries are distinct with their own advantages and disadvantages. But as far as surgical clearance of the cancer is concerned one has not been shown to superior to the other. Hence the choice of surgery in these cases depends on the treating surgeon.
For the tumors of lower thoracic esophagus we prefer to carry out total esophagectomy as described in the section above.
For the tumors of junction of stomach and esophagus- the choice of surgery is based on patient factors and how much stomach needs to be resected for safe margins. This is decided based on the findings of endoscopy and CT scan.
Partial esophagogastrectomy :
In this surgery only a potion of lower esophagus and portion of stomach are removed in continuity such that a margin of 5cm of normal tissue is retained around the cancer.
This can be achieved by
(a) only one large incision extending from the abdomen onto the lower chest on the left side. This is called the left thoraco-abdominal approach ( LTA)
(b) two separte incisions- one in the abdomen ( to mobilize the stomach) and one in the right side of chest ( to mobilze the lower esophagus) . This is called Ivor-Lewis technique .
We usually don’t prefer using LTA, because we feel the dissection of esophagus and nodal clearance is not adequate in all the cases. And it causes significant amount of pain in the post operative period. Hence our preference in this scenario is Ivor Lewis approach.
In Ivor Lewis approach, the abdominal part of the surgery is carried out first. This can be achieved either by laparoscopic/robotic surgery or open surgery.
The stomach tube is prepared in a similar fashion like in total esophagectomy. Then the patient is turned to the left and thoracic part of the surgery is carried out. We prefer to do this by thoracoscopy. The lower thoracic part of the esophagus is dissected. Esophagus is divided atleast 5 cm from the tumor. Then the previosuly prepared stomach tube is pulled into the stomach and joined with the help of a stapler.
Using intra oral circular stapler: Joining ( anastomosis) esophagus to the stomach in thorax is challenging. A circular stapler that can be inserted from the mouth into the esophagus comes in real handy to achieve the anastomosis quickly.