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  • Surgical Procedures for Esophageal Cancer

    Surgery is the initial procedure in the treatment of many solid cancers. Surgery and other invasive procedures work by removing cancerous tissues.
    To treat esophageal cancer, an esophagectomy may be done in an effort to remove some or all of the cancerous tissue. Other invasive procedures may be done to help provide nutrition when the esophagus shuts down. These include placing a feeding tube and maintaining a channel through the esophagus. These last two procedures are referred to as palliative, because their goal is to relieve symptoms, not to cure the cancer.
    Psychotherapy may have an important role to play in the care of patients admitted to the hospital for esophageal cancer surgery. Researchers randomly divided 271 surgical patients with cancers affecting the gastrointestinal tract ( esophagus , stomach , liver , pancreas , colon , or rectum) into two groups: one received usual care on the surgical ward and the other received formal psychological support in addition to usual care. Psychological interventions, which were provided both before and after surgery, consisted of emotional and cognitive support and help in planning for the future. Ten years after their surgery, patients who received psychological support were significantly more likely to be alive than those who did not receive such additional care.

    Esophagectomy

    Esophagectomy is the complete removal of the diseased portion of the esophagus and all associated tissues that might contain cancer. This surgery is not even considered in 60% of cases. Even when it is attempted, the procedure is frequently unsuccessful and has a high mortality rate immediately following surgery that accounts for 5% to 10%. This is due to the frequently weakened and malnourished status of the patient by the time the diagnosis is made, the difficulty of the surgery, and its proximity to many vital organs. Aggressive surgery, however, may be justified, particularly for some patients with lesions in the lower half of the esophagus.
    Description of the Procedure
    For this procedure, both the chest and the upper abdomen have to be exposed. The esophagus lies at the very back of the chest, behind the heart and breathing tubes, both of which have to be moved out of the way or worked around.
    It may be that the surgeon, after exploring the cancer site, decides that the planned procedure cannot be successful and decides against it. If he or she chooses to go ahead, the first step is to identify all tissue that needs to be and can be removed. Since this includes the esophagus, a replacement must be found.
    Most often the stomach is pulled up into the chest and attached to the upper end of the esophagus, above the cancer. In some cases, a synthetic tube or a piece of small intestine is substituted for the missing piece of esophagus.
    Along with the diseased portion of the esophagus, the surgeon will remove every suspicious lymph node he or she can find. Few other organs in the area can be removed, even partially, thus limiting the usefulness of surgery for widely spread disease.
    Your stay in the hospital may extend over several weeks due to the extensive nature of the surgery and the high rate of severe complications. Once you are home to recover, it may take even longer before you feel comfortable.
    Effectiveness
    Cure rates for this procedure are quite poor and comparable to primary treatment with radiation . Somewhat better results are obtained for combinations of chemotherapy and radiation or of all three modalities.
    Possible Complications
    Complications of esophagectomy are many and severe. This is because the procedure is complex and risky. Also, people are often weakened by the disease before going into surgery, and are therefore more prone to complications. Possible complications include the following:
    • Reaction to anesthesia or other medications used during surgery
    • Bleeding
    • Serious infections in the chest and/or abdomen
    • Leakage from any of the surgical connections that have been made—These leakages are always serious since the material that leaks is not sterile.
    • Subdiaphragmatic abscess—This refers to an accumulation of pus beneath the diaphragm. The abscess is the result of a leakage of intestinal contents into the upper abdomen. It usually requires surgical drainage and intensive treatment with antibiotics.
    • Anastomotic fistula—This is an abnormal passage inside the body created during the surgery. The result is leakage of air and infected material into critical locations. Leakage into the chest is even more serious than leakage into the abdomen, and it is made worse by the presence of stomach acid. Treating this complication involves surgical drainage with removal of all foreign material and intensive treatment with antibiotics, if the patient can tolerate it.
    Postoperative Care
    After an esophagectomy, you will be in an intensive care unit (ICU) for many days while your lungs, circulation, and digestive tract heal. You will be very closely monitored. You may receive nutrition through intravenous fluids and total parenteral nutrition (TPN). TPN is the injection of nutrients directly into a major vein, therefore bypassing your digestive tract. There are many possible complications during recovery from any surgery, particularly a major surgery such as an esophagectomy:
    • Shock lung—Also called adult respiratory distress syndrome (ARDS), this reaction prevents the lungs from adequately exchanging oxygen.
    • Disseminated intravascular coagulation (DIC)—Abnormalities of blood clotting cause uncontrollable bleeding.
    • Kidney failure—Several mechanisms can lead to an interruption of kidney function, which can be restored with prompt treatment.
    • Circulatory collapse—The heart and blood vessels may cease supporting blood pressure. Intensive treatment is required to keep organs and the patient alive until effective blood circulation can resume on its own.
    • Sepsis —Certain infections can enter the blood stream and travel to every part of the body. Intensive antibiotic treatment plus circulatory and kidney support are required to treat the infection before it becomes fatal.

    Palliative Procedures

    Most efforts to improve your comfort and prolong your useful life will be attempts to get nutrition into you when your esophagus is blocked off. In advanced stages of obstruction, you will not even be able to swallow saliva, so choking and aspiration into your lungs will be a constant threat.
    Feeding Tubes
    A feeding tube can be inserted through your abdominal wall and directly into your stomach or small intestine in order to feed you when you cannot swallow. This will help prevent starvation and also help prevent aspiration of material into your lungs.
    The feeding tube can be placed as part of another surgical procedure or as a separate out-patient procedure. Once the rubber tube is placed through your skin and into your stomach or small bowel, it is fixed securely, both inside and out, and plugged. The procedure itself takes little time, can be done during laparoscopy or gastroscopy, and has few complications. It will add no time to your hospital stay or to your recovery from other treatments.
    Effectiveness of Feeding Tubes
    This procedure always accomplishes its purpose. Complete, balanced liquid meals can be delivered through the tube at any time.
    Possible Complications
    Bleeding, infection, or irritation where the tube exits the abdomen are the only likely problems with feeding tubes.
    Postoperative Care
    Once you have a feeding tube placed, your nurse will help you care for it. This involves keeping the wound site clean, changing the dressings, and monitoring the site for any signs of infection.
    Maintaining a Channel Through the Esophagus
    There are a few methods for keeping a route open through relatively natural passages:
    • Laser fulguration through an endoscope—Tissue that is obstructing the passageway is burned away. This appears to be the most promising of these methods. The effectiveness and specificity of laser treatments can be enhanced by giving you certain chemicals that localize in the cancer tissue and make it more sensitive to the laser. This is called photodynamic therapy (PDT).
    • Dilation of the esophagus by passing probes of increasing diameter through the narrowing passageway—This can be done either blindly or through endoscopy. Endoscopy is the insertion of a fiberoptic tube with a lighted tip (an endoscope) through the mouth and down through the gastrointestinal (GI) tract to allow the doctor to view the entire passageway from mouth to stomach.
    • Tubular metal devices—These can be placed to bypass the tumor.
    Effectiveness
    Each of these three methods is temporarily effective in allowing you to eat, or at least to drink, but the cancer is still growing and will eventually prevent further attempts to maintain an opening.
    Possible Complications
    The main complications of these methods are the following:
    • Failure to open an adequate channel
    • Perforation of the esophagus
    Postoperative Care
    Some healing time will be required after each of these procedures, during which other methods of nourishing will be used. Depending upon the type of procedure and your response to it, you will start on liquid food when your doctor thinks it is safe.

    References

    Esophageal cancer. National Cancer Institute website. Available at: http://www.nci.nih.gov/cancerinfo/wyntk/esophagus . Accessed December 2, 2002.

    Harrison's Principles of Internal Medicine. 14th ed. McGraw-Hill; 1998.

    Neoplasms of the esophagus. American Cancer Society website. Available at: http://www.cancer.org/docroot/home/index.asp . Accessed November 30, 2002.

    9/18/2007 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Küchler T, Bestmann B, Rappat S, Henne-Bruns D, Wood-Dauphinee S. Impact of psychotherapeutic support for patients with gastrointestinal cancer undergoing surgery: 10-year survival results of a randomized trial. J Clin Oncol. 2007;25:2702-2708.

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