General Surgery
Perspective on Malignant Esophageal Disease (A)
Built from Maingot's Abdominal Operations
What’s inside
14 sections · 84 slides
About this perspective
A senior esophageal surgeon comments on three reviews, and says where he would do things differently
- Purpose and scope of this perspective
- Themes running through the commentary
The rise of esophageal adenocarcinoma
The largest epidemiologic change ever recorded for a solid cancer, and a hypothesis about what drives it
- Scale and pattern of the rise
- Reflux of stomach contents into the esophagus
- The acid-suppression hypothesis
- Symptom relief on medication and cancer odds
- How a higher gastric pH lets bile acids act
- From acid suppression to adenocarcinoma
- Why severe persisting symptoms may carry less risk
- Squamous, intestinalized and gastric linings meeting in one field
- Goblet cells in intestinalized columnar lining
Surveillance in Barrett's esophagus
Taking issue with the dogma that watching a Barrett segment does not save lives
- Surveillance and survival: the current dogma
- Stage at detection in their own series
- Surveillance biopsies in the lower esophagus
Defining the gastroesophageal junction
A boundary nobody can agree on, and the effect that has on counting cancers
- Cardia cancers in the new staging system
- Where the esophagus meets the stomach
- The 2000 anatomic definition and its limits
- A histologic definition of the junction
- Types of metaplastic columnar lining
- Consequences of counting the junction correctly
High-grade dysplasia and endoscopic therapy
How far endoscopy can go before the esophagus has to come out
- High-grade dysplasia as the threshold for treatment
- Endoscopic mucosal ablation versus esophagectomy
- Visible lesions inside a flat Barrett segment
- Depth of invasion decides the treatment
- Depth of tumour invasion through the esophageal wall
- The wall layers that matter for this decision
- No safe level of submucosal invasion
- Glandular cancer beneath the surface lining
- Irregular malignant glands at high power
- Training, workload and safety of endoscopic therapy
- Patients unsuited to esophageal preservation
- Normal hiatus compared with a hiatal hernia
- Vagal sparing esophagectomy
- Removing the diseased segment and rejoining the esophagus
Choosing the operation
Where the tumour sits decides what is done to it
- When resection remains the mainstay
- Treatment chosen by tumour site
- Cervical cancer close to the cricopharyngeus
- Lower cervical and upper thoracic tumours
- Bowel used to replace the esophagus
- Mid thoracic, lower thoracic, junction and cardia tumours
- Stomach pulled up into the chest after total esophagectomy
- Partial esophagectomy and rejoining
Margins in an en bloc resection
Clear edges in three directions, and what happens when they are not
- The three margins that must be clear
- Proximal margin length and specimen shrinkage
- Radial margin and survival
Lymphadenectomy
How many nodes to remove, and the one prognostic factor the surgeon controls
- Node count as a survival predictor
- Ranking of the prognostic factors
- Esophageal cancer spread to nearby lymph nodes
- The third field: cervical node dissection
- Nodes found during the initial neck dissection
En bloc versus transhiatal resection
Which patients actually gain from the bigger operation
- Design of the comparison
- What the comparison showed
- Node count and the probability of systemic disease
Ischemia of the reconstruction conduit
The complication the author calls the Achilles heel of esophageal resection
- Why the conduit is the weak point
- Factors that contribute to conduit ischemia
- Managing a worrisome conduit at operation
- Delayed reconstruction after an ischemic conduit
- Results of the delayed strategy
Chemotherapy and chemoradiation
Two decades of trials, and why the author thinks they answered the wrong question
- Why the trials multiplied
- Where the evidence stands
- The staging flaw in the current trials
- What neoadjuvant therapy actually achieves
- Two trial designs worth running
- Definitive chemoradiation and the case against surgery
- < 2%
- Centralization of esophageal surgery
Technique of the tri-incision esophagogastrectomy
Where this unit's version of the McKeown operation differs in detail
- Starting in the right chest
- Skeletonizing the aorta
- Azygos vein and thoracic duct
- Scar lines left by esophageal cancer surgery
- Chest drainage after the resection
- Effect of that drainage plan
- Abdominal skeletonization
- Exposing the inferior wall of the portal vein
- Gastric conduit and pyloroplasty
Minimally invasive esophagectomy
What keyhole access has delivered, and where its limit lies
- What the minimally invasive approach has delivered
- Keeping the extent of the dissection
- The limit of minimal access
Key points
What to carry away from this perspective
- Key points: disease and diagnosis
- Key points: treatment decisions
- Key points: complications and the future
- References
- References (continued)
- Maingot's Abdominal Operations, 12th Edition