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Surgical management of esophageal cancer

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Surgical management of esophageal cancer

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    1. Surgical management of esophageal cancer Richard I. Whyte, MD, MBA Professor of Cardiothoracic Surgery Stanford University Medical Center

    2. Epidemiology and Demographics Esophageal cancer is not particularly common but incidence is rising rate of increase has outstripped all other tumors adenocarcinoma has replaced squamous as most frequent type of esophageal neoplasm increase in adenocarcinoma related to Barrett’s mucosa

    10. BARRETT’S ESOPHAGUS “INTESTINAL METAPLASIA” incidence of Barrett’s: 0.45-2.2% of all upper endoscopies 12% of endoscopies for reflux 0.4% of general population approx. 700,000 people in U.S.

    13. Clinical Presentation Dysphagia Odynophagia Retrosternal or epigastric pain Hoarseness (recc. nerve palsy)

    14. Evaluation History and Physical Barium swallow Endoscopy CT EUS Bone scan PET

    15. Diagnosis / evaluation

    20. Staging – T status Tis…carcinoma in situ; same as Barrett’s w/ high-grade dysplasia T1…invades lamina propria or submucosa T2…muscularis propria T3…invades adventitia T4…adjacent structures

    21. Staging – N Status N0…No regional node metastases N1…1-2 regional node metastases N2…3-6 regional nodes N3…7 or more regional nodes

    23. Esophageal Cancer Treatment Surgery Preoperative chemo-Radiation Postoperative chemo’ (+/- rad’) Chemo’ alone Radiation alone Definitive chemo-radiation Palliative treatment (stenting, etc)

    24. Esophagectomy Ivor-Lewis…laparotomy, right thoracotomy, +/- neck incision Transhiatal esophagectomy Left thoracotomy (thoracoabdominal) En bloc (radical) esophagectomy Minimally invasive Robotic

    25. Esophagectomy – options Route Substernal Mediastinal Subcutaneous Extent of resection Standard Radical

    26. Surgical Options

    27. Surgical Options-Choices Conduit Stomach Colon Small bowel Location of conduit Location of anastomosis neck Chest Type of anastomosis Hand-sewn stapled

    28. Surgical Options-Choices Conduit Stomach Colon Small bowel Location of conduit Location of anastomosis neck Chest Type of anastomosis Hand-sewn stapled

    29. Transhiatal esophagectomy Popularized by Orringer Utilizes transhiatal and cervical approaches to mobilize intrathoracic esophagus Potential advantages of less pain, fewer pulmonary complications, lower anastomotic leak morbidity

    34. Ivor Lewis Esophagogastrectomy Laparotomy & Right Thoracotomy Named after a Welsh surgeon (1895-1982)

    37. Left thoracoabdominal

    38. Minimally invasive (or robotic) Modification of Ivor Lewis or transhiatal Laparoscopy, VATS, thoracic or neck anastomosis

    43. EMR relies on early detection Relies on pathologic examination and negative margins Relationship between depth of invasion and likelihood of nodal involvement Applicable to squamous and adeno’ Follow-up endoscopies necessary Will likely result in lower mortality but higher recurrence

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