OPERATIONS FOR

ESOPHAGEAL MOTOR DISORDERS Symptom relief:

AND
DIVERTICULA -improvement of esophageal contraction
amplitude
Long Esophageal Myotomy for Motor -amelioration of non-peristaltic waveforms.
Disorders of the Esophageal Body
*Prokinetic agents:
*Long esophageal myotomy -may increase esopha-geal contraction
amplitude
=indicated for: (doesn’t alter the prevalence of simultaneous
-dysphagia caused by any motor disorder waveforms)
characterized by segmental or generalized
simultaneous waveforms in a patient whose *Severely compromised efficacy of
symptoms are not relieved by medical therapy esophageal propulsion:

-disorders: =effective waveforms during meals

-diffuse and segmental esophageal drops below 30%
spasm =high prevalence of simultaneous
-vigorous or type 3 achalasia waveforms
-nonspecific motility disorders
associated with a mid- or epiphrenic Tx:
esophageal diverticulum surgical myotomy of the esophageal
body to improve dysphagia
*Decision to operate made by a balanced *Preoperative high-resolution manometry
evaluation of the patient’s: =essential to determine the proximal extent of
-symptoms the esophageal myotomy in patients selected
-diet for surgery
-lifestyle adjustments =can extend myotomy distally across the LES
-nutritional status => reduce outflow resistance.
-most important factor:
improving the patient’s *Antireflux protection
swallowing disability. =needed to avoid gastroesophageal reflux if
with extensive dissection of the cardia.
*symptom of chest pain alone:
-not an indication for a surgical procedure *Partial fundoplication
=to not add back-resistance that will further
*Effective contractions: interfere with the ability of the myotomized
-peristaltic waveforms consisting of esophagus to empty.
contractions with an amplitude above 30
mmHg *Reflux symptoms pre-op
=> 24-hour pH monitoring to confirm
*Likely to experience dysphagia:

-effective contractions drops below 50%

during meals
 2 Techniques(Myotomy) =>excised by dividing the neck with a
stapler sized for the thickness of the
1) Open technique diverticulum

= performed through a left thoracotomy in the =>followed by a closure of the

sixth intercostal space muscle over the staple line

= incision made in the posterior mediastinal (+)midesophageal diverticulum

pleura over the esophagus
=>myotomy includes:
= left lateral wall of the esophagus is exposed
- muscle around the neck
= esophagus is not circumferentially dissected - diverticulum suspended by attaching
unless necessary it to the paravertebral fascia of the
thoracic vertebra above the level of
= 2-cm incision made into the abdomen the diverticular neck
through the parietal peritoneum at the
midportion of the left crus. *Before esophageal diverticulum operation:
-endoscope the patient to wash all food and
= tongue of gastric fundus pulled into the other debris from the diverticulum.
chest
-exposes the GEJ and its associated fat *Most gain or maintain weight after the
pad which is excised to give a clear operation.
view of the junction
2) Thoracoscopic technique
= myotomy through all muscle layers
-extend distally over the stomach = may be performed through the left or right
1 to 2 cm below the GEJ chest.
-proximally on the esophagus over the
distance of the manometric =most surgeons combine:
abnormality.
= muscle layer dissected from the mucosa Right thoracoscopic long myotomy with an
laterally for a distance of 1 cm. abdominal approach for Heller myotomy
+
= divide all minute muscle bands with care partial fundoplication
esp. the GEJ area

= gastric fundic tongue sutured to the margins *both done at the same setting
of the myotomy over a distance of 3 to 4 cm *by double positioning the patient
and replaced into the abdomen *may be done at two operations
-maintains separation of the muscle
and acts as a partial fundoplication to
prevent reflux. *do the abdominal component first
(+)epiphrenic diverticulum =>esophageal outflow obstruction
-source of most of the
symptoms
POEM Myotomy of the Lower Esophageal
Sphincter (Heller Myotomy)
PO -Peroral
E - endoscopic *Achalasia
M- myotomy
=second only to reflux disease
= new procedure that allows a long myotomy
to be performed from the lumen of the =most common functional disorder of the
esophagus with an endoscope. esophagus to require surgical intervention.

= for those with type 3 achalasia (vigorous =Goal of treatment:

achalasia) -relieve the functional outflow obstruction
secondary to the loss of relaxation and
= procedure starts by opening the esophageal compliance of the LES.
mucosa several centimeters above the spastic
segment with a needle–knife electrosurgery =results in symptomatic improvement with
device passed through an endoscope. the occasional return of esophageal peristalsis.
=extremely minimally invasive and can be
=Hydrostatic balloon dilation
done on an outpatient basis.
=Cannot be treated with POEM: -reduces LES resistance intraluminally
-Epiphrenic diverticula (laparoscopy with
division of LES {Heller myotomy} instead) -ruptures the sphincter muscle, by botulinum
toxin injection, or by a surgical myotomy that
(Fig. 25-62) cuts the sphincter.

*Inflammatory reaction to diverticulum *Botulinum toxin injection

= make the transhiatal dissection difficult =may best be used as a diagnostic tool,
= safer to perform diverticulectomy through a when it is not clear whether a hypertensive
right thoracoscopic approach LES is the primary cause of dysphagia.

*Post-op ff. diverticulectomy: *Responsiveness to botulinum toxin injection

=patient on NPO or on clear liquids for 5 to 7 may predict a good response to Heller
days myotomy.

=contrast study obtained before advancing to *Pneumatic dilation

a full liquid or “mushy food” diet =achieves adequate relief of dysphagia and
pharyngeal regurgitation in 50% to 60% of
=Solid foods withheld for 2 weeks to decrease patients
the likelihood of staple line leak. =if dilation fails -> myotomy is indicated
=Buttressing or sealing the staple line with
fibrin glue also an option.
*Where balloon dilation is dangerous and
surgery is the better option:
= dilated and tortuous esophagus
= an associated hiatal hernia
*Surgical myotomy as a primary treatment *Even though a myotomy or balloon rupture
gives better long-term results of the LES muscle reduces the outflow
obstruction at the cardia, the underlying motor
*Submucosal inflammatory response disorder in the body of the esophagus persists
and deteriorates further with the passage of
= most intense in the first 6 to 12 weeks after time, leading to increased impairment of
injection. esophageal emptying.
= wait at least 3 months after botulinum toxin
*The earlier an effective reduction in outflow
injection to perform cardiomyotomy
resistance can be accomplished, the better the
- minimize the risk of encountering outcome will be, and the more likely some
dense inflammation esophageal body function can be restored.

*Myotomy of the LES can be accomplished * 4 important principles in performing a

via either: surgical myotomy of the LES:

a) abdominal approach (a) complete division of all circular and

collar-sling muscle fibers
=preferred in the absence of a previous
upper abdominal surgery (b) adequate distal myotomy to reduce
outflow resistance
= laparoscopy results in less pain and
a shorter length of stay than (c) “undermining” of the muscularis to allow
thoracoscopy wide separation of the esophageal muscle

=a bit easier to ensure a long gastric (d) prevention of postoperative reflux

myotomy when the approach is
transabdominal. *Laparoscopic cardiomyotomy
(Heller myotomy)
b) thoracic approach =treatment of choice for most patients with
achalasia.
*If an antireflux procedure is used as an
adjunct to esophageal myotomy, a complete
Open Esophageal Myotomy
360° fundoplication should be avoided.
*Open techniques of distal esophageal
*Use the ff. to avoid long-term esophageal myotomy
dysfunction secondary to the outflow used to
avoid the long-term esophageal dysfunction = rarely used outside reoperations
secondary to the outflow obstruction afforded
by the fundoplication itself: = primary procedures can almost always be
successfully completed via laparoscopy.
a) 270° Belsey fundoplication
b) Toupet posterior 180° fundoplication
c) Dor anterior 180° fundoplication
*Modified Heller myotomy:
*Best objective evaluation of improvement in
=can be performed through a left thoracotomy the patient following either balloon
incision in the sixth intercostal space along dilation or myotomy:
the upper border of the seventh rib. = scintigraphic measurement of
esophageal emptying time
=myotomy through all muscle layers is
performed, extending distally over the *When an antireflux procedure is added to the
stomach to 1 to 2 cm below the junction, and myotomy, it should be a partial fundoplication.
proximally on the esophagus for 4 to 5
cm. *360° fundoplication
= associated with progressive retention of
=Cardia reconstructed by suturing the tongue swallowed food, regurgitation, and
of gastric fundus to the margins of the aspiration to a degree that exceeds the
myotomy: patient’s preoperative symptoms.
-to prevent rehealing of the myotomy
site Laparoscopic Cardiomyotomy
-to provide reflux protection in the
area of the divided sphincter = more commonly known as a laparoscopic
Heller myotomy
* Belsey repair
= “double myotomy”
-performed if an extensive dissection of the
cardia has been done = the laparoscopic approach is similar to the
Nissen fundoplication in terms of the trocar
*Tongue of gastric fundus is allowed to placement and exposure and dissection of the
retract into the abdomen. esophageal hiatus

*Nasogastric drainage is maintained for 6 *procedure begins by division of the short

days to prevent distention of the stomach gastric vessels in preparation for
during healing. fundoplication.

*An oral diet is resumed on the seventh day, *Exposure of the GEJ via removal of the
after a barium swallow study shows gastroesophageal fat pad follows.
unobstructed passage of the bolus into the *Anterior vagus nerve
stomach without extravasation. = swept right laterally along with the fat pad
*Vigorous achalasia *Distal esophageal myotomy is performed.
=simultaneous esophageal contractions are *It is generally easiest to begin the myotomy
associated with the sphincter abnormality 1 to 2 cm above the GEJ, in an area above that
of previous botulinum toxin injections or
=Myotomy should extend over the balloon dilation.
distance of the abnormal motility as
mapped by the preoperative motility study *An antireflux procedure follows completion
-failure to do this will result in of the myotomy.
continuing dysphagia
*Either an anterior hemifundoplication -scintigraphic assessment of esophageal
augmenting the angle of His (Dor) or emptying time
posterior partial fundoplication (Toupet) can
be performed. *Postdilation LES pressure

*Dor type fundoplication -the most valuable measurement for

=slightly easier to perform, and it does not predicting long-term clinical response.
require disruption of the normal posterior
gastroesophageal attachments (a theoretical -a postdilatation sphincter pressure <10
advantage in preventing postoperative reflux). mmHg => good response.

Per Oral Endoscopic Myotomy (POEM) *The addition of an antireflux procedure if

the operation is performed transthoracically
- ultimate minimally invasive myotomy as it has no significant effect on the outcome.
requires no incisions through the skin.
*Intraoperative complications of laparoscopic
- With this procedure, a very effective myotomy and hemifundoplication converted
myotomy is performed entirely from the to an open procedure:
lumen of the esophagus. -mucosal perforation => more likely to
occur after botulinum toxin injection
- Started by opening the esophageal mucosa
10 cm above the lower esophageal sphincter *Best treatment for achalasia:
with a needle–knife electrosurgery device -laparoscopic Heller myotomy and
passed through an endoscope. partial fundoplication.

- A long submucosal plane is developed with

the endoscope, down to and below the LES. Esophageal Resection for End-Stage Motor
Disorders of the Esophagus
- can be done on an outpatient basis.
*Best managed by esophagectomy:
-Patients with dysphagia
- major downside: effective antireflux valve
-long-standing benign disease
cannot be created, exposing the patient to a
=>esophageal function has been
40% to 50% risk of GERD post procedure
destroyed by the disease process or
Outcome Assessment of the Therapy for
multiple previous surgical procedures,
Achalasia
are best managed by esophagectomy.
Critical analysis of the results of therapy for
motor disorders of the esophagus requires *Fibrosis of the esophagus and cardia
objective measurement. => result in weak contractions and failure of
the distal esophageal sphincter to relax
*A variety of objective measurements may be -loss of esophageal contractions can
used to assess success: result in:
-stasis of food
-LES pressure -esophageal dilatation
-regurgitation
-esophageal baseline pressure -aspiration
*Presence of abovementioned abnormalities =an autosomal dominant
signals endstage motor disease. disorder characterized by
=> esophageal replacement usually hyperkeratosis of the palms
required to establish normal and soles)
alimentation. -human papillomavirus

*Consider choice of the organ to substitute *Adenocarcinoma of the esophagus seen in

for the esophagus before proceeding with association with smoking and alcohol
esophageal resection for patients with end-
stage benign disease: =always originates in Barrett’s mucosa and
Ex: resembles gastric cancer
-stomach
-jejunum =rarely arises in the submucosal glands
-colon
= forms intramural growths that resemble the
If minimally invasive esophagectomy is to be mucoepidermal and adenoid cystic
performed: carcinomas of the salivary glands
=> thoracoscopic dissection
combined with abdominal dissection == most important etiologic factor in the
development of primary adenocarcinoma of
*MIS transhiatal esophagectomy for the the esophagus is a metaplastic columnar-lined
massively dilated esophagus or Barrett’s esophagus, which occurs in
=>may result in large volume bleeding approximately 10% to 15% of patients with
from mediastinal vessels that become GERD.
enlarged with esophageal dilation
*Esophageal carcinoma
CARCINOMA OF THE ESOPHAGUS =prevalence is exploding, largley secondary
to the well-established association among
*Squamous carcinoma
gastroesophageal reflux, BE, and esophageal
=> accounts for the majority of esophageal
adenocarcinoma.
carcinomas worldwide.
=gross appearance resembles that of
*Suggested environmental factors responsible
squamous cell carcinoma.
for localized high-incidence areas:
-additives to local foodstuffs (nitroso
*Endoscopic surveillance for patients with BE
compounds in pickled vegetables and
is recommended for two reasons:
smoked meats)
-mineral deficiencies (zinc and
(a) at present there is no reliable evidence that
molybdenum)
medical therapy removes the risk of
-smoking and alcohol consumption
neoplastic transformation
*Definite associations linked squamous
(b) malignancy in BE is curable if detected at
carcinoma:
an early stage.
-long-standing achalasia
-lye strictures
-tylosis
Clinical Manifestations 60% of the esophageal circumference is
infiltrated with cancer.
*Esophageal cancer
=usually advanced if symptoms herald its
=generally presents with dysphagia.
presence.
=Extension of the primary tumor into the
tracheobronchial tree can occur primarily with *Usually precede the onset of dysphagia with
squamous cell carcinoma and can cause: tumors of the cardia:
-stridor -anorexia
-tracheoesophageal fistula -weight loss
-coughing
-choking *Physical signs of esophageal tumors
-aspiration pneumonia =associated with the presence of
-severe bleeding from the primary distant metastases.
tumor or from erosion into the aorta or
pulmonary vessels occurs (rare)
General Approach to Esophageal Cancer
* Most common cause of vocal cord paralysis: *Esophageal cancer dictated by the stage of
=> Invasion of the left recurrent laryngeal the cancer at the time of diagnosis.
nerve by the primary tumor or LN metastasis
*Determine if:
*Systemic organ metastases: -T1–T2, N0 = disease confined to the
=> usually manifested by jaundice or bone esophagus
pain -T1–3, N1= locally advanced
-Any T, any N, M1 = disseminated

*The most prominent early symptom in high-

incidence areas where screening is practiced: *Cancer confined to the esophagus
=> the most prominent early symptom =removal of the tumor with adjacent
is pain on swallowing rough or dry lymph nodes may be curative
food.
*Addressed with endoscopic treatment:
*Back pain at the time of esophageal cancer =Very early tumors con-fined to the
diagnosis mucosa:
=>there is usually distant metastasis or -T in situ
celiac encasement. -T1a
-intramucosal cancer
*Dysphagia
= usually presents late in the natural history of *Multimodality approach in a surgically fit
the disease patient:
=> lack of a serosal layer on the =>when the tumor is locally
esophagus allows the smooth muscle aggressive
to dilate with ease
=becomes severe enough for the patient to *Multimodality therapy is either:
seek medical advice only when more than a) chemotherapy followed by surgery
or radiation
b) chemotherapy followed by surgery
 -peritoneal surfaces:
*Neoadjuvant or induction therapy -omentum
=treatments given before surgery -small bowel mesentery

*Disseminated cancer *Positron emission tomography (PET)

-Tx: aimed at palliation of symptoms scanning
=to tell whether the masses are metabolically
*Endoscopic placement of an expandable active (likely to be cancer) or not when the
esophageal stent masses that are identified are not
=most rapid form of palliation in characteristic for cancer or are in a location
patients with dysphagia that precludes resection with the cancer
specimen.
*Radiation
=first choice for palliation of GEJ cancer *A PET active focus corresponding to a mass
(stents placed across the GEJ create a great on CT scan outside of the field of esophageal
deal of gastroesophageal reflux) resection should be biopsied before resection
is performed.

Staging of Esophageal Cancer *Endoscopic ultrasound (EUS)

=made it possible to identify patients who are
*Staging starts with the history and physical. potentially curable before surgical therapy.
=Using an endoscope, the depth of the
*M1a disease: wall penetration by the tumor and the
-LN disease remote from the tumor, presence of LN metastases can be determined
particularly in the cervical region, may be with 80% accuracy.
palpable on neck examination and generally *Curative resection
indicates cancer dissemination -should be encouraged if EUS indicates that
the tumor has not invaded adjacent organs
-these patients should not be treated with (T4b)
therapy directed toward locally advanced -fewer than six enlarged LNs are imaged
cancer.
*Diagnostic laparoscopy and jejunostomy
*Umbilical LN in GEJ cancer tube placement
= meta-static LN that is rarely palpable but -occasionally may precede induction
equally ominous chemoradiation in the patient with
severe dysphagia and weight loss from
*Computed tomographic (CT) scanning of the a locally advanced cancer.
chest, abdo-men, and pelvis
=provides information on local *Esophageal cancer
invasion of the primary cancer, LN =diagnosed with endoscopic biopsy
involvement, or disseminated disease
=staged with CT scanning of the chest and
*Most common sites of esophageal cancer abdomen, EUS
metastases:
-lung
-liver
=PET scan for all patients with CT or EUS differently from those of the thoracic
evidence of advanced disease (T2 or greater, esophagus.
N1-2 or NX). =drain directly into the paratracheal
and deep cervical or internal jugular
*Factors known to be important in the LNs with minimal flow in a
survival of patients with advanced disease: longitudinal direction.
-cell type
-degree of cellular differentiation *Except in advanced disease, it is unusual for
-location of tumor in the esophagus intrathoracic LNs to be involved.
(factors have no effect on survival of patients
who have undergone resection for early *Cervical esophageal cancer
disease) =frequently unresectable because of early
invasion of the larynx, great vessels, or
*Patients having five or fewer LN metastases trachea.
have a better outcome. =Radical surgery, including
esophagolaryngectomy
Clinical Approach to Carcinoma of the -may occasionally be performed for
Esophagus and Cardia these lesions but less desirable
*The selection of a curative vs. a palliative approach due to morbidity
operation for cancer of the esophagus is based
on: *Stereotactic radiation + chemptherapy
-location of the tumor =most desirable treatment for most patients
-patient’s age and health with cervical esophageal cancer
-extent of the disease
-preoperative staging *Squamous carcinomas
-most common tumors that arise
I. Tumor Location within the middle third of the
esophagus
*8% of the primary malignant tumors of the
esophagus occur in the cervical portion (Fig. -frequently associated with LN
25-68). metastasis, which are usually in the
thorax but may be in the neck or
*Almost always squamous cell cancer abdomen, and may skip areas in
between.
*Adenocarcinoma rare arising from a
congenital inlet patch of columnar lining *Midthoracic cancer and abdominal LN
metastases are incurable with surgery
These tumors, particularly those in although some emerging data that suggest that
the postcricoid area, represent a cervical LN metastases, if isolated, can be
separate pathologic entity for two resected with benefit.
reasons:
(a) they are more common in females *T1 and T2 cancers without LN metastases
and appear to be a unique entity in this =generally treated with resection only
regard =LN involvement or transmural cancer (T3)
(b) the efferent lymphatics from the warrants treatment with neoadjuvant
cervical esophagus drain completely chemoradiation therapy followed by resection.
 II. Age
*Resection of midesophageal cancer should
be performed under direct vision with either *> 80 years
thoracoscopy (video-assisted thoracic surgery -resection for cure of carcinoma rarely
[VATS]) or with thoracotomy. indicated because of the additional
operative risk and the shorter life
expectancy
*Tumors of the lower esophagus and cardia
=> usually adenocarcinomas -If w/ high-performance status and
excellent cardiopulmonary reserve
*Because of the propensity of GI tumors to =considered candidates for
spread for long distances submucosally, long esophagectomy
lengths of grossly normal GI tract should be
resected. -reduced the morbidity and mortality
*The longitudinal lymph flow in the associated with open two- or three-
esophagus can result in skip areas, with small field esophagectomy.
foci of tumor above the primary lesion
=underscores the importance of a wide III. Cardiopulmonary Reserve
resection of esophageal tumors
=10-cm margin of normal esophagus *Respiratory function
above the tumor =best assessed with the forced
expiratory volume in 1 second, which
*There is no submucosal lymphatic barrier ideally should be 2 L or more.
between the esophagus and the stomach at the
cardia =Poor candidate for thoracotomy:

*50% of the local recurrences in patients with -any patient with a forced
esophageal cancer who are resected for cure expiratory volume in 1 second
occur in the intrathoracic stomach along the of <1.25 L
line of the gastric resection.
-40% risk of dying from
*Length of the esophagus =17 to 25 cm respiratory insufficiency
*Length of the lesser curvature of the stomach within 4 years
=approx.12 cm
*Transhiatal esophagectomy
*In most patients with carcinoma of the distal = for patients with poor pulmonary
esophagus or cardia: reserve
-curative resection with cervical = as the pulmonary morbidity of this
division of the esophagus and a operation is less than is seen following
>50% proximal gastrectomy thoracotomy.

*Clinical evaluation and electrocardiogram

=>not sufficient indicators of cardiac
reserve
*Echocardiography and dipyridamole *Pronounced dysphagia and associated
thallium imaging malnutrition
=>provide accurate information on => addressed before the initiation of
wall motion, ejection fraction, and chemoradiation
myocardial blood flow
*Laparoscopic jejunostomy tube
=>defect on thallium imaging may =can be placed prior to induction therapy or at
require further evaluation with the time of esophagectomy.
preoperative coronary angiography
*A resting ejection fraction of <40%, *5 days’ pretreatment with immune-
particularly if there is no increase with enhancing nutrition, rich in fish oils,
exercise decreases cardiac and other complications,
=an ominous sign following esophagectomy.

*In the absence of invasive testing: V. Clinical Staging

=stair-climbing is an economical
method of assessing cardiopulmonary *Clinical factors that indicate an advanced
reserve. stage of carcinoma and exclude surgery
=climb three flights of stairs without with curative intent are:
stopping -recurrent nerve paralysis
-will do well with two-field -Horner’s syndrome
open esophagectomy -persistent spinal pain
especially if an epidural -paralysis of the diaphragm
catheter is used for -fistula formation
postoperative pain relief. -malignant pleural effusion

IV. Nutritional Status *Factors that make surgical cure unlikely

-factor most predictive of postoperative include:
complication -tumor >8 cm in length
-abnormal axis of the esophagus on a
*higher rate of complications and mortality: barium radiogram
=Profound weight loss -more than four enlarged LNs on
more than 20 lb CT
associated with hypoalbuminemia -weight loss more than 20%
(albumin <3.5 g/dL) -loss of appetite
*Favorable parameters:
*Malnourished patients = favorable for tumors <4 cm in length
-generally have locally advanced =fewer with tumors bet. 4 and 8 cm
esophageal cancer or metastatic =no favorable criteria for tumors >8
disease cm in length
=> placement of a feeding tube
before the beginning of *Tumor >8 cm in length
induction chemoradiation =excluded in curative resection
therapy
*Smaller tumor => aggressive approach in tx
VI. Preoperative Staging With Advanced *It is difficult to provide modern treatment of
Imaging esophageal cancer without access to this
modality.
*Backbone of esophageal cancer staging:
-clinical staging b) PET scanning
-contrast radiography
-endoscopy =usually combined with an axial CT scan
-CT scanning (CTPET)

*Recently,preoperative decision making is =usually is performed on patients with locally

guided by: advanced cancer or questionable lesions on
CT scan
a) Endoscopic ultrasonography(EUS) => to determine whether metastases
=most reliable method of determining are present
depth of cancer invasion
=uses the injection of radiolabeled
*If enlarged LNs (-), the degree of wall deoxyglucose
invasion dictates surgical therapy. => taken up in metabolically active
tissues such as cancer
*Endoscopic mucosal resection (EMR)
=preferable option if a small focus of *PET-positive areas correlated with the CT
esophageal cancer is confined to the mucosa scan findings
=> to assess the significance of
*Esophagectomy with LN dissection “hot spots.”
=if the tumor invades into the submucosa,
without visible lymph node involvement *CTPET scanning
= useful before the initiation of
* Induction chemoradiation therapy chemoradiation therapy.
(neoadjuvant therapy)
=if EUS demonstrates spread through the wall *If a PET-avid tumor shows no change in
of the esophagus, especially if LNs are metabolic activity after 2 weeks of induction
enlarged chemoradiation therapy, it is unlikely that
further chemo- or radiation therapy will be of
*Surgical resection is rarely indicated: any benefit.
=when the EUS demonstrates invasion of the => worse prognosis
trachea, bronchus, aorta, or spine => may be referred for resection or
palliation without incurring the
*Surgical resection considered: morbidity or expense of a full course
=if there is invasion into the pleura of chemo- and radiation therapy.
(T4a) in the absence of a malignant
effusion

*Therapy of esophageal cancer is largely

driven by the findings of an endoscopic
ultrasonography.
Palliation of Esophageal Cancer =may be used to seal fistulae or when stent
removal becomes desirable in the future.
=indicated for:
-individuals with metastatic esophageal *Uncovered expandable metal stents
cancer = treatment of choice when large, locally
-cancer invading adjacent organs (T4b) who invasive tumors or metastatic esophageal
are unable to swallow, cancer precludes any future hope of resection
-individuals with fistulae into the *Major limitations to stenting exist in cancers
tracheobronchial tree at the GEJ:
*Aortic esophageal fistulas -A stent placed across the GEJ will
=extremely rare and nearly 100% lethal. result in severe gastroesophageal
reflux and heartburn that can be quite
*Dysphagia as a result of esophageal cancer disabling
=can be graded from grade I, eating normally, =>radiation therapy alone may
to grade VI, unable to swallow saliva be preferable
*Grades I to III *Laparoscopic jejunostomy
=often can be managed with radiation therapy, =usually the procedure of choice if feeding
usually in combination with chemotherapy. access is desirable
*Definitive chemoradiation therapy
=term used to describe when surgical Surgical Treatment
resection is not anticipated in the future
=usually palliative *Surgical treatment of esophageal cancer is
dependent upon:
=Radiation dose increased from 45 Gy to 60
-the location of the cancer
Gy administered over 8 weeks, rather than the
4 weeks given for chemoradiation induction -depth of invasion
therapy.
-LN metastases
*Although some of these patients are truly
cured, cancer will recur in many either locally -fitness of the patient for operation
or systemically 1 to 5 years following -culture and beliefs of the individuals
definitive chemoradiation.
- institutions in which the treatment is
*After a 12-month wait from initial treatment performed.
and no other sites of tumor detectable except
the esophagus, some of these patients may be
candidates for salvage esophagectomy. *Esophagectomy
=should not be performed if an R0
*For individuals with dysphagia grades IV resection is not possible.
and higher, additional treatment generally is
necessary. =if the surgeon does not believe he or
=>Mainstay of therapy: she can remove all LNs invaded by
in-dwelling esophageal stents cancer and provide a tumor-free radial
*Covered removable stents margin and esophagus
 and stomach margins that are tumor *Small intramucosal carcinomas may be
free removed with EMR in the following manner:
=>a resection should not be =The area beneath the nodule is infiltrated
performed with saline through a sclerotherapy needle
=A specialized suction cap is mounted on the
Mucosally Based Cancer end of the endoscope, and the nodule is drawn
up into the cap; a snare is then applied to
*Subcentimeter nodules are frequently resect the tissue.
discovered in patients with BE especially
those with high-grade dysplasia =Alternatively, a rubber band can be
delivered, and the snare can be used to
*Nodules resected in entirety, as they often resect above the level of the rubber band. This
harbor adenocarcinoma. specimen is then removed and sent to
pathology.
*Resection can be performed with:
=a transhiatal esophagectomy =As long as the tumor is found to be confined
=EMR to the mucosa and all margins are negative,
the resection is complete.
*EMR
=offers another method for removing *A positive margin or involvement of the
intramucosal cancer submucosa
=> warrants esophagectomy
=typically combined with EUS to rule => high risk for developing small nodular
out more invasive disease carcinomas elsewhere in their Barrett’s
segment
=unable to differentiate between =>routine surveillance on a 3- to 6-
cancer that is confined to the mucosa month basis must be continued
(T1a) and that which invades the indefinitely.
submucosa (T1b)
*Alternative aproach:
*Not amenable to endoscopic mucosal -Radiofrequency ablation of the remainder of
resection: the high-grade dysplasia after careful
=tumors invading the submucosa surveillance biopsy specimens demonstrate no
=>high-frequency (20–25%) further sign of cancer.
concurrent finding of positive => this approach to the early
LNs cannot be removed esophageal cancer should not be used
without esophagectomy when there is any suspicion of
mediastinal or abdominal
*Intramucosal cancers lymphadenopathy.
= little risk of spreading to regional LNs.

=Approach:
-performing EMR on all nodules identified in
a field of Barrett’s esophagus
-T staging is performed by histologic analysis.
Minimally Invasive Transhiatal *Retrograde esophageal stripping
Esophagectomy
=>performed by dividing the
*Mini-invasive surgery (MIS) transhiatal esophagus below the GEJ and sliding
esophagectomy a vein stripper from the neck down
=operation combines the advantages into the abdomen followed by an
of transhiatal esophagectomy at inversion of the esophagus in the
minimizing pulmonary complications posterior mediastinum and removal
with the advantages of laparoscopy through the neck
(less pain, quicker rehabilitation).
=>reserved for patients with high-
*High-grade dysplasia or intramucosal grade dysplasia.
carcinoma
=> vagal sparing procedure *For small cancers at the GEJ:
-vagal trunks are separated from the
esophagus at the level of the -esophagus stripped in an antegrade
diaphragm and the lesser curvature fashion by sliding the vein stripper
dissection of the stomach allows the down from the cervical incision and
vagus and left gastric pedicle to out the tail of the lesser curvature
remain intact.
- tail of the lesser curvature is pulled
- provides no LN staging and is thus out a port site high in the epigastrium
inadequate for all high-grade dysplasia while the esophagus is inverted into
and intramucosal cancer. itself.

*MIS transhiatal esophagectomy is usually *For GEJ cancers:

performed through: -a wide celiac access LN dissection,
=five or six small incisions in the upper splenic artery, hepatic artery, and
abdomen a transverse cervical incision for posterior mediastinal LN dissection
removing the specimen and performing the can be performed as well or better
cervical esophagogastrostomy. than through a laparotomy

*Use a vein stripping “inversion” technique -gastric conduit is pulled up to the

=> to remove the esophagus from the neck with a chest tube and
posterior mediastinum anastomosed to the cervical esophagus
in an end-to-side fashion using a
=> includes the laparoscopic creation of a surgical stapler or with a handsewn
neo-esophagus (gastric conduit) along the anastomosis.
greater curvature of the stomach using the
right gastroepiploic artery as the primary =Complications:
vascular pedicle. -leak from the esophagogastric
anastomosis
=>A Kocher maneuver releases the duodenum, => self-limited and
and a pyloroplasty may be performed usually heals within 1
(optional). to 3 weeks,
spontaneously