1. Esophageal Cancer Approx. 13,000 cases/year in USA
Post-esophagectomy overall 5 yr survival = 18%
At presentation, 57% patients are Stage 3, with a 10% post-esophagectomy surv.
At presentation, 24% patients are Stage 2, with a 35% post-esophagectomy surv.
At presentation, patients who are Stage 1, have an 80% post-esophagectomy surv.

2. Esophageal CA -- pre-op staging
TNM staging somewhat overbroad
If T1, but tumor is in mucosa only:
Lymph node metastases < 10%
If T1, but tumor extends into submucosa:
Lymph node metastases = approx. 30
Distant mets, lymph nodes, wall penetration

3. Esophageal CA -- find distant mets
CT chest and abdomen -- mostly useful in trying to detect distant mets
but, CT chest and abdomen -- only 60% accurate in detecting regional lymph node disease
but, CT chest and abdomen -- underestimates tumor stage in 40% of patients
Addition of PET may improve accuracy

4. Esophageal CA -- find distant mets
Bronchoscopy in proximal and middle third esophageal CA’s
eval. for posterior tracheal invasion
“slight compression” still resectable
“abnormal tracheal mucosa” unresectable

5. Esophageal CA -- eval. lymph nodes
Lymph node status
Thoracoscopic staging can find LNs, but poorly predicts unresectability
Laparoscopic staging can change treatment in 30% of distal esophageal Cas
Matted celiac nodes
Carcinomatosis
Small liver lesions

6. Esophageal CA -- eval. lymph nodes
Lymph node status
Laparascopic staging
Laparscopic ultrasound of liver not useful

7. Esophageal CA -- pre-op staging
Wall penetration
Endoscopic ultrasound -- incorrect in determining wall depth 15-20% of the time
Endoscopic ultrasound -- incorrect in determining nodal status % of the time
Endoscopic ultrasound -- less accurate after neoadjuvant therapy

8. Esophageal CA -- pre-op staging
Wall penetration
“High grade dysplasia” = 43% occult adeno CA
Tumor limited to submucosa --> 19% LN involvement
3% had more than 4 nodes
Nodes limited to peri-esophageal, not spleen or peri-gastric => no need to resect these
Invasion of muscularis propria --> 80% LN involvement

9. Esophageal CA -- chemoradiation
Treatment of choice for Stage 4 (mets)
Stent esophageal lesion, chemo and radiation
SCC responds to radiation better than Adeno CA

10. Esophagectomy -- Types of operations
Incision strategies:
Ivor-Lewis
Laparotomy, thoracotomy
Transhiatal
Conduit strategies:
Gastric pull-up
Colonic interposition
Jejunal interposition

11. Esophagectomy -- Types of operations
Anastomosis strategies:
Location:
Cervical
Intrathoracic
Anastomotic technique does not affect leak rate
Radiation, vascular supply does
Post-op feeding strategies:
Jejunosotmy feeding tube placed at time of esophagectomy

12. Esophagectomy -- Types of operations
Anastomosis strategies:
Technique:
Stapled (EEA)
Ease
Strictures
Sutured
single layer vs double layer, running vs interrupted

13. Esophagectomy -- Types of operations
Anastomosis strategies:
Tension issues
Tacking sutures not often used in stapled anastomoses
Gastric emptying strategies
15% pyloric obstruction rate
Pyloroplasty, pyloromyotomy ?
+/- Graham patch
Vagotomy

14. Esophagectomy -- Intra-operative complications
Bleeding
average < 800 cc for Ivor-Lewis
transhiatal esophagectomy bleeding
left thoracoabdominal extension vs. left thoractomy
Aortic a., bronchial a., azygous v. bleeding --> pack, then upper sternal split
Tracheobronchial injury
secure airway by advancing ETT, then repair
primarily vs. pedicled flap buttress

15. Esophagectomy -- Intra-operative complications
Recurrent laryngeal nerve injury
especially in cervical dissections

16. Esophagectomy -- Operation by stage
Barrett’s esophagus with High-grade dysplasia or intramucosal adeno-CA
No visible tumor on endoscopic U/S
but again, U/S may not be accurate in distinguishing mucosal vs. submucosal confinement
Vagal sparing esophagectomy, transhiatal esophagectomy
If no regional disease detected

17. Esophagectomy -- Operation by stage
Barrett’s esophagus with High-grade dysplasia or intramucosal adeno-CA
No visible tumor on endoscopic U/S
but again, U/S may not be accurate in distinguishing mucosal vs. submucosal confinement
Investigational: Mucosal ablation (laser, photodynamic), endoscopic mucosal resection

18. Esophagectomy -- Operation by Stage
Tumor confined to submucosa on U/S
Visible tumor on endoscopic U/S
75% have tumor past mucosa into submucosa and beyond when seen on U/S
56% have lymph node metastases (both limited to and extending past submucosa)
Extended transhiatal esophagectomy
Complete lower mediastinal and upper abdominal lymph node resection
since only 19% had LNs if limited to submucosa
not “en bloc” since only 3% had > 4 LNs

19. Esophagectomy -- Operation by Stage
Tumor into or through muscularis propria
75% to 85% LN involvement
45% have > 4 LNs
% have distant LNs involved (25% celiac LNs)
radical en bloc esophagectomy (DeMeester)
1-5 % local recurrence rate
however, most surgeons do not perform radical en bloc resections, relying on adjuvant therapy
35% local recurrence operation alone (i.e. not “en bloc”)

20. Esophagectomy -- Operation by Stage
Radical en bloc esophagectomy (DeMeester)
1-5 % local recurrence rate
Compare 35% local recurrence overall after esophagectomy
Five-year survival for Stage 3 is %
Compare overall five-year Stage 3 post-esophagectomy survival rate of 10%
Cervical lymph node dissection
Mid-thoracic tumors and upper third tumors have 45% cervical lymph node mets

21. Esophagectomy -- Operation by Stage
Cervical lymph node dissection
Mid-thoracic tumors and upper third tumors have 45% cervical lymph node mets
No survival advantage to cervical LN resection (Nishimaki, 1999)
Exception was 1 to 4 LNs (but how can you tell in advance?)
Significant additonal morbidity (80%) with additional lymph node (“three-field”) dissection

22. Esophagectomy -- Complications
Mortality 3 - 5%, Morbidity 15-18%
Anastomotic leaks %
Cervical
leak rate 0-12%, post-op day 5-10
fever, crepitance, drainage, erythema, leukocytosis
requires wide incision and drainage, not repair
1/3 develop stricture --> I&D (not repair)

23. Esophagectomy -- Complications
Thoracic --> Gastrograffin swallow vs. CT
With-hold feeding additional 5-7 days if < 1 cm contained leak
Repeat esophagogram
Exploration if free leak or > 1 cm contained leak (risk of erosion by mass effect)
Pediatric endoscope at exploration time (?)
Assess for large disruptions or necrosis of conduit

24. Esophagectomy -- Complications
Conduit necrosis or large disruptions
Resect anastomosis, debride edges
End cervical diverting esophagostomy
Gastric remnant returned to abdomen
Drainage
Reconstruction in several months

25. Esophagectomy -- Complications
Conduit obstruction at diaphragm
Two fingers width alongside conduit at diaphragm
Resect head of left clavicle, first rib, manubrium in cervical anastomoses as needed
Diaphragmatic bowel herniation
Prevent by suturing conduit to hiatus with sutures
Vague lower thoracic/upper abd. cramping pains
CXR; CT or contrast study if in doubt
Repair with hiatal closure and anchoring sutures

26. Esophagectomy -- Complications
Chylothorax
1 - 3%
Ligate intraoperatively when identified
Massive (800 cc/day) chest tube output at days post-op vs. tension chylothorax if no Chest Tube
Feed cream -- note change in chest tube character
Stop enteral feeds; start TPN
Explore promptly and ligate thoracic duct through right thoracotomy, VATS, or prior thoracotomy

27. Esophagectomy -- Complications
Anastomotic strictures %
More often if lye, leak, small EEA staplers, suture technique, irradiation
Requires dilatation (80% dilatation success)
Early after leak
Combined with endoscopy
Use 46 Fr or larger Maloney dilators, balloons when necessary
Repeat until 6 months of stability
use extra care if colon, small bowel conduit
Chronic (> 12 mo) cervical anastomotic strictures
Stricturoplasty / SCM flap (50% failure) / Lat. Dorsi flap / free radial arm flap / pectoralis myocutaneous flap (like ENT flaps)

28. Esophagectomy -- Complications
Delayed hemorrhage (rare)
Consider splenic injury
Aspiration pneumonia -- 3%
Videoesophagogram before re-feeding 5-7 days
Dysphagia
Regurgitation
Delayed emptying
Only 15% develop pyloric obstruction
Balloon dilatation, erythromycin, metoclopramide
Dumping

29. Esophagectomy -- Post-op diet
Smaller, more frequent meals
Drink liquids after meals to avoid gastric distension
Avoid high carbohydrate diets
Liberal anti-diarrheal use
Dumping symptoms usually resolve in months

30. Esophageal CA -- radiation
20 to 40 Gy over weeks (1.75 to 3.75 Gy/fx)
Squamous cell carcinoma -- more radiosensitive
Preoperative radiation versus surgery alone
no improved survival in long-term randomized trials
Post-op radiation versus surgery alone
no improved survival, but higher stricture rate
improved local recurrence rates in node negative mid- to upper-third SCCs

31. Esophageal CA -- chemo Pre-operative chemo (Cisplatin, 5-FU)
Only 19% response
No change in survival
No change in local recurrence rates or patterns

32. Esophageal CA -- chemoradiation
Pre-op chemoradiation (cisplatin/5-FU)
40% (histologic) response rate (average)
Similar response rates for SCC and AdenoCA
Response rate dependent on time to surgery following chemoradiation
What is ideal delay to surgery?
In rectal CA, 6-8 week gap allows more restorative surgery than does a 2 week gap
Allow healing ability to recover
Allow clinical tumor shrinkage

33. Esophageal CA -- chemoradiation
Pre-op chemoradiation (cisplatin/5-FU)
Increases surgical M/M by 5-15%
With high does rad’n (high dose (3.5 Gy) /fraction (TE fistula)
Anastomotic leaks, strictures
Toxicities
myelotoxicity if Mitomycin C, etoposide, vinblastine added
Average results, not controlled by delay to surgery

34. Esophageal CA -- chemoradiation
Pre-op chemoradiation (cisplatin/5-FU)
Non-significant improvements yet seen
Urba(2001, AdenoCA only) : 3 year survival 16% --> 30% (P=0.15)
Local recurrence 41% --> 19%
Clark(2000abstract) : 2 year 35% --> 45% (P=.002)
median survival difference 4 months, short F/U
Walsh (1996, adenoCA only) : highly controversial: 6% --> 32%
Bossett(1997, Stage 1 and 2 SCC only): no difference

35. Esophageal CA -- chemoradiation
Pre-op chemoradiation (cisplatin/5-FU)
Survival differences may be lost by 5 years
Benefits not yet substantiated by long-term studies (2002 review)

36. Esophageal CA -- chemoradiation alone
Chemoradiation instead of surgery
Studies show pathologic and clinical response rates comparable to historical esophagectomy survivals in Stage 2 and 3 carcinomas
EORTC trial in progress Gy with 5 FU/Cisplatin
Comparisons are not against “en bloc” resections

37. Esophageal CA -- chemoradiation alone
Chemoradiation (CRT) instead of surgery
40-60% of CRT alone die with local recurrence/failure
Compare 9% with CRT plus surgery
Surgical salvage following CRT alone
no difference in salvage versus CRT alone

38. Esophageal CA -- chemoradiation alone
Chemoradiation instead of surgery
Current methods to determine complete (clinical) response are inadequate to predict which patients might not require surgery in addition to chemoradiation
Endoscopic U/S or MRI -- accuracy inadequate in determining local and regional tumor
PET, CT -- can’t detect regional nodes well
Histologic response -- not avail. without resection
Future: biologic serum markers ?