Oesophageal Surgery

1. Oesophageal Surgery Mike Poullis

2. What Is It? • Surgery on the oesophagus • Cancer of the oesophagus • Ruptured Boerhaaves Syndrome • Reflux disease • Strictures • Achalasia

3. Anatomy

4. Normal Oesophagus

5. Cancer of the Oesophagus

6. Type and Location of Tumours of Oesophagus • Type • Adenocarcinoma • Squamous • Location • Lower third Adenocarcinoma • Middle third • Upper third Squamous

7. Investigating Oesphageal Cancer Patients • History • Examination • Special investigations • CXR • ECG • PFTs • CT • Oesophgoscopy • Endooesphageal ultrasound • Barium • Manometry • 24hr pH

8. CXR

9. ECG

10. PFTs • FVC and FEV1 • Major risk of surgery is respiratory complications

11. Zones of the oesophagus

12. CT Lower Third

13. CT Middle Third

14. Oesophgoscopy

15. Oesophgoscopy

16. Endo-oesphageal ultrasound

17. Barium

18. Manometry

19. 24hr pH

20. Unresectable oesophageal cancer

21. 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

22. What are the operations at CTC? • Left thoracophrenotomy +/- neck anastomosis • Ivor Lewis • McKeown

23. Left thoracophrenotomy +/- neck anastomosis • Tumour location • Lower third • Incision • Resect tumour • Mobilise • Re anastomose ? Neck ? thorax

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

31. Ivor Lewis

32. Incision

36. McKeown • Ivor Lewis with a neck anastomosis

37. 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. • Ndescriptor • 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. • For tumours of upper thoracic oesophagus: • Mia. Metastasis in cervical lymph nodes. Ml b. Other distant metastasis.

38. Outcome T1a Tumor invades lamina propria T1b Tumor invades submucosa Lymph node 5-year metastasissurvival rate T1a 0% 100% T1b 47% 86% without nodal metastasis 43% with nodal metastasis

39. Outcome • N1 Regional lymph node metastasis • N1a 1-3 nodes involved • N1b 4-7 nodes involved • N1c >7 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

40. 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

41. Post Operative Leaks • Always think leak to explain anything!

42. Ruptured Oesophagus Boerhaaves Syndrome

43. Reflux disease

44. Strictures

45. Achalasia

46. Thankyou

47. Next week23rd NovemberThoracic Surgery ComplicationsLecture Theatre