Oesophageal Surgery

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Oesophageal Surgery

• Mike Poullis

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What Is It?

• Surgery on the oesophagus
• Cancer of the oesophagus
• Ruptured Boerhaaves Syndrome
• Reflux disease
• Strictures
• Achalasia

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Normal Oesophagus
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Cancer of the Oesophagus
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Type and Location of Tumours of Oesophagus

• Type
• Adenocarcinoma
• Squamous
• Location
• Lower third Adenocarcinoma
• Middle third
• Upper third Squamous

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Investigating Oesphageal Cancer Patients

• History
• Examination
• Special investigations
• CXR
• ECG
• PFTs
• CT
• Oesophgoscopy
• Endooesphageal ultrasound
• Barium
• Manometry
• 24hr pH

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CXR
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ECG
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PFTs

• FVC and FEV1

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CT Lower Third
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CT Middle Third
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Oesophgoscopy
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Oesophgoscopy
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Endo-oesphageal ultrasound
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Barium
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Manometry
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24hr pH
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What are the operations?

• Left thoracophrenotomy
• Ivor Lewis
• McKeown
• Orringer Transhiatal esophagectomy (THE)
• Transabdominal
• En Bloc resection
• Endothoracic endooesophageal pull through
• Total gastrectomy and Roux-en-Y reconstruction
• Thorascopic eosphagectomy

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What are the operations at CTC?

• Left thoracophrenotomy /- neck anastomosis
• Ivor Lewis
• McKeown

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Left thoracophrenotomy /- neck anastomosis

• Tumour location
• Lower third
• Incision
• Resect tumour
• Mobilise
• Re anastomose ? Neck ? thorax

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Ivor Lewis

• Tumour location
• Middle third
• Incision
• Abdominal
• Thoracic
• Resect tumour
• Mobilise
• Re anastomose ? Neck ? thorax

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Incision
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McKeown

• Ivor Lewis with a neck anastomosis

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Staging

• T descriptor
• Tis. Carcinoma in situ.
• TI. Tumour does not extend into the muscularis
  propria.
• T2. Tumour invades muscularis propria.
• T3. Tumour extends beyond the muscularis propria
• T4. Tumour invades adjacent structures.
• N descriptor
• NO. No regional lymph-node metastasis.
• NI. Regional lymph-node metastasis.
• Regional lymph nodes are difficult to define
  lower thoracic lymph node metastases from a
  cervical oesophageal tumour are considered
  distant (M) disease, as are coeliac lymph node
  metastases from a lower-third oesophageal
  carcinoma.
• M descriptor
• No distant metastases.
• Distant metastases.
• For tumours of lower thoracic oesophagus
• Mla. Metastasis in coeliac lymph nodes. M lb.
  Other distant metastasis.
• For tumours of mid-thoracic oesophagus
• Mia. Not applicable. Mib. Nonregional lymph node
  or other distant metastasis.

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Outcome

• T1a Tumor invades lamina propria
• T1b Tumor invades submucosa
• Lymph node 5-year metastasis survival
  rate
• T1a 0 100
• T1b 47 86 without nodal metastasis
• 43 with nodal metastasis

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Outcome

• N1 Regional lymph node metastasis
• N1a 1-3 nodes involved
• N1b 4-7 nodes involved
• N1c gt7 nodes involved
• 2-year 5-year Median survival survival
  survival rate rate (months)
• N1a 22 11 12
• N1b 18 0 9
• N1c 0 0 6

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Post Operative Complications

• Early complications ( days 0 to 5) include
• Poor urine output and low blood pressure
• Bleeding
• Respiratory complications
• Medical comorbidity
• Intermediate complications ( days 3 to 10)
  include
• The septic patient
• DVT and PE
• Medical comorbidity
• Late complications ( days 5 to 10) include
• Anastomotic leaks and new onset atrial
  fibrillation
• Aspiration
• Chyle leaks
• The septic patient
• DVT and PE
• Medical comorbidity

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Post Operative Leaks

• Always think leak to explain anything!