Role of Surgery in CA Oesophagus

1. Surgery for
Carcinoma Esophagus
Dr L.Anand
MS MCh FRCS DNB
Associate Professor
Institute of Surgical Gastroenterology
Madras medical College

2. Management Options
•SURGERY
• Chemoradiation
• Radiation
• Sandwich therapy
• Stents

3. Still undetermined
Paucity of scientific information
Raging debates
________________________
No consensus

4. Carcinoma Oesophagus
Surgery is the Mainstay
In Resectable Disease!

5. Issues:
1. Relief of dysphagia
2. Aim towards zero operative mortality
3. Reduced hospital stay and morbidity
4. Better ‘Q O L’
5. Protection against recurrence
6. Prolong survival if possible

6. The two ends in Surgery…….
• Transhiatal Oesophagectomy
• En-bloc oesophagectomy with two or three field
lymphadenectomy

7. Access –OPEN
• Thorax – Abdomen(Iwor Lewis)
• Thorax – Abdomen – Neck(McKeown)
• Thoracoabdominal(Sweet procedure)
• Transhiatal(Orringer)

8. Access -MAS
• Thoracoscopy & Laparotomy
• Laparoscopy and Thoracotomy
• VATS & Laparoscopy
• Total MIS

9. How much clearance?
Axial
Radial
Nodal

10. OPEN
Ivor Lewis

11. McKeown

13. Mckeown : Neck Anastomosis

14. Mckeown: Post op

15. Mckeown: Post op

16. Trans hiatal Esophagectomy

17. THE: Gastric Tubularisation

18. THE: Neck Dissection

19. THE: Neck Anastomosis

20. THE : Specimen

21. VATS

22. Placement of ports

23. Azygos vein being ligated

24. Mobilisation of Oesophagus
with tumor

25. Laparoscopic Mobilisation

26. Lap mobilisation stomach

27. Gastric conduit being created

28. Taking up of conduit

29. Specimen delivered
through the neck

30. Neck Anastomosis

32. Adjacent organs
• What can be removed ?
–Pleura
–Pericardium
–Diaphragm
–Crura
–Thoracic duct with lymphnodes

33. Adjacent organs
• What cant be removed?
–Aorta
–Trachea
–Bronchus
–RLN

34. Lymphadenectomy
• How much to do?
– 2 field(mediastinal/abdomen)
– 3 field(mediastinal/abdomen/neck)

35. Lymphadenectomy
• Number , Region or Both?

36. 3 F L N D
Adheres to oncological principles

38. Lymphadenectomy
At what expense ?
Morbidity and Mortality

40. Complications - 2 F L N D
n Leak Pulmonary RLN
Injury
Death
Lerut et al. 54 12 11 - 7.4
Nishihara et al. 30 8 13 - 7
Altorki 78 13 24 4 5.1
Fujita 65 11 49 48 3

41. T H E Complications
n Year leak R L N Pulmon
ary
Death
Orringer MB 800 2001 13 7 2 4
Gupta 250 1996 15 14 3 6
Tilanus 141 1993 26 16 17 5
Vigneswaran 131 1993 24 12 12 2.3

42. Q O L ?

43. Which procedure to choose ?
1.THE
2.TTE
3.MAS

44. 44 Series 1986-1996
• 2675 THE
• 2808 TTE
No difference in mortality and
long term survival
Simon Law & John Wong, 2001

45. • Altorki et al (non randomised trial)
– 4 yr survival – Enbloc esophgectomy
– 37% - TTE vs 11% THE
• Hulscher et al 2002(RCT)
– RCT : TTE vs THE
– 5 yr survival
– TTE: 39% THE: 27% p= 0.08
– MARGINAL STATISCAL SIGNIFICANCE
– Morbidity upto 60% for TTE

46. Issues for Enbloc Esophgectomy
• Increase time of surgery and anesthesia
• Prolonged Post op ICU Stay
• Length of hospitalisation >14 days
• Morbidity significantly higher
– needs close monitoring with various specialists
• Mortality – similar (TTE vs THE)
• Survival – marginally better
– (Altorki et al and Skinner et al )
• ?QOL

47. Justification for T H E
Subtotal oesophagectomy possible
Adjacent organ removal
Abdominal and lower mediastinal node removal
(PINOTTI)
Relief of dysphagia
BETTER Q O L

48. Justification for T H E
Avoiding Thoracotomy
Has it made any difference ?
Hulscher JBF et al. T H E has lower pulmonary complications…
N Eng J Med 2002;347:1662-69

49. Review of Minimal Access

50. Palanivelu et al 2006
J Am Coll Surg 2006 Vol :203 (1) : 7 -16
Minimally Invasive Esophagectomy : Thoracoscopic
mobilisation of the EsophagusAnd Medicastinal
Lymphadenectomy in prone Position :
Experience of 130 patients

51. Palanivelu et al 2006
• Respiratory complications: Very minimal
• Anastomotic leak 2.31 %
• Peri- operative mortality 1.54%
• Median Hospital stay : 8Days
• No tracheal/ lung injury
• Stage specific survival was similar
– between open/MAS at 20 months fU

52. MAS
• It has potential to replace
other convential type of Eosphagectomies

53. To be studied
• RCT for
– THE vs MAS
– TTE vs MAS

54. Thank you