Esophageal Ca Managememmnt 2021 (2).pptx

jjj

1. ESOPHAGEAL CANCER MANAGEMENT By Dr. Abdulmenan Abduljelil ( R-4 ) 8 June 2021 5/5/2021 1 By Abdulmenan Abduljelil

2. OUTLINES Epidemiology risk factors Screening and diagnosis Diagnostic and staging workup Treatment of esophageal cancer Surgical approaches of esophagectomy Palliative treatment 5/5/2021 2 By Abdulmenan Abduljelil

3. EPIDEMIOLOGY Esophageal cancer is a disease primarily of men ( male:female ratio, 3:1) that occurs in the sixth and seventh decades of life with a median age of 67 years. In the United States, the incidence is 4.5 per 100,000 population, whereas in China it may be as high as 140 per 100,000 population The incidence of adenocarcinoma in White men is roughly three times that in Black men, whereas the incidence of SCC of the esophagus is six times higher in Blacks. The rapid growth in the incidence of eso . ca increasing obesity and reflux increased awareness: on the part of the medical community as well as pt -SCC remains the most frequent histologic subtype of esophageal cancer globally There has been a marked change in the epidemiology of this disease in North America and Europe In US, SCCaccounted for roughly 90% of esophageal cancers in the 1960s. However, recent data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database indicate that the incidence of adenocarcinoma actually has surpassed that of squamous cell carcinoma. 5/5/2021 3 By Abdulmenan Abduljelil

4. RISK FACTORS Studies from high-incidence geographic areas have reported strong statistical associations b/n various environmental risk factors and the development of esophageal SCC There is a plausible link between GERD, BE, and esophageal adenocarcinoma Only a fraction of individuals progress to invasive adenocarcinoma , It is more likely that environmental risk factors interact with molecular genetic alterations Tobacco has been shown to increase the risk of esophageal cancer approximately 10-fold, alcohol abuse increases the risk from 20- to 50-fold. the combination of tobacco and alcohol use may increase the risk 100-fold. . 5/5/2021 4 By Abdulmenan Abduljelil

5. Adenocarcinoma has a stronger association with tobacco use, whereas squamous cell carcinoma is more closely linked to alcohol use Diets rich in carbohydrate and low in animal protein, green vegetables, and fruit were associated with the dev/t of esoph cancer Cholesterol consumption in the form of butter may contribute to a large proportion of esophageal cancers in high risk areas in France. Diets high in nitrosamines and foods contaminated with molds ( Fusarium ) and fungus ( Geotrichum candidum ) also have been Diets in which hot liquids are consumed. Diets low in beta carotene, vitamins B and C, magnesium, and zinc Environmental exposure to asbestos, perchloroethylene , and radiation 5/5/2021 5 By Abdulmenan Abduljelil

6. Inflammation and Carcinogenesis It is generally accepted that BE is an acquired condition resulting from GERD. Reflux of duodenal contents has been suggested as an important contributing factor in the pathogenesis of esophagitis and BE It is hypothesized that GERD ↓ results in acute mucosal injury ( esophagitis ), ↓ promotes cellular proliferation, and induces specialized columnar metaplasia (Barrett’s epithelium) of the normal squamous epithelium 5/5/2021 6 By Abdulmenan Abduljelil

7. Clinical Manifestations Esophageal cancer generally presents with dysphagia, Dysphagia usually presents late in the natural history of the disease Dysphagia becomes severe enough for the patient to seekmedical advice only when more than 60% of the esophageal circumference is infiltrated with cancer. It can progress to odynophagia and eventually to complete obstruction. Pain may be transient, associated with swallowing or constant. It may be retrosternal or epigastric in location. Weight loss may be due to dietary changes, starvation, or tumor anorexia. 5/5/2021 7 By Abdulmenan Abduljelil

8. A Patients may experience regurgitation of undigested food Asymptomatic patients are now frequently identified on surveillance endoscopy, Nonspecific upper GI symptoms and undergo screening endoscopy. Patients may develop respiratory sequelae ( Stridor,cough , choking,pneumonia primarily from aspiration direct invasion of tumor into the tracheobronchial tree TEF, usually involving the left mainstem bronchus Extension of the primary tumor into TBT can occur primarily with SCC Patients may become severely dehydrated, even hypokalemic , because of their inability to swal low potassium-rich saliva 5/5/2021 8 By Abdulmenan Abduljelil

9. Vocal cord paralysis (Hoarseness) - invasion of vocal cord - invasion of RLN Severe bleeding from the primary tumor or from erosion into the aorta or pulmonary vessels occurs Systemic organ metastases are usually manifested by jaundice or bone pain the situation is different in high-incidence areas where screening is practiced. In patients that present with back pain at the time of esophageal ca diagnosis, there is usually distant mets or celiac encasement With tumors of the cardia , anorexia and weight loss usually precede the onset of dysphagia Asymptomatic patients in a Barrett’s surveillance program may be identified at an early stage when the disease is 5/5/2021 9 By Abdulmenan Abduljelil

10. Physical examination May reveal entirely normal findings and Generally does not aid in the Dx Temporal wasting, weight loss, and dehydration can be seen It is important to look for physical findings that may alter the therapeutic approach, supraclavicular or cervical adenopathy , or an abdominal mass Laboratory examinations Anemia from chronic blood loss, Hypoproteinemia from malnutrition, and Hypercalcemia and abnormal LFT from distant mets Hypercalcemia in 15% of patients with esophageal SCC 5/5/2021 10 By Abdulmenan Abduljelil

11. Prevention and Screening For Esophageal ca. For SCC prevention consists of Smoking cessation Reduce alcohol abuse Consumption of diet containing adequate amount of fruits,vegetables , and vitamins For esophageal adenocarcinoma prevention involves stopping the sequenceof events leading from GERD  BE  adenocarcinoma Better control of GERD can prevent development of Barrett metaplasia in patients with GERD and discourage the development of HGD in pts with metaplasia Endoscopic followup evaluation should be performed at 1-2yr interval to detect presence of dysplasia, allowing intervention before cancer develops 5/5/2021 11 By Abdulmenan Abduljelil

12. Surveillance upper endoscopy with biopsy should be considered for pts who have one of the following hereditary cancer predisposition syndromes associated with increased risk for esophageal and GEJ cancers: Tylosis Familial Barrett esophagus Bloom syndrome Fanconi anemia The goal of endoscopic surveillance is prevention of cancer or early case detection of EAC and appropriate therapy to improve on the poor global survival of EAC (5-year all-case survival in 1997 of 13%). Currently, endoscopic surveillance is driven by the grade of dysplasia (an unequivocal neoplastic change in the cytology and architecture of the glandular tissue ) 5/5/2021 12 By Abdulmenan Abduljelil

13. If no dysplasia is present in the first two endoscopies, then repeat endoscopy every 3 to 5 years is sufficient. If LGD is found, it should be reconfirmed as the worst lesion; then annual endoscopy is sufficient. The management of HGD is controversial and needs to be individualized based on the patient’s risk aversion to cancer and to operative mortality, comorbidity , the stage of the lesion, and the local institutional expertise. The biopsy protocol is four-quadrant every 2 cm for no dysplasia and for LGD. For HGD, 4 quadrant biopsies should be performed every 1cm. 5/5/2021 13 By Abdulmenan Abduljelil

14. Diagnosis and Staging Workup ● Chest radiography Has a minimal role in the modern Dx and staging of eso ca. can reveal abnormal finding in almost half of the pts in some countries it is still used routinely to identify hilar or mediastinal LAP evidence of pulmonary metastases, 2ry pulmonary infiltrates caused by aspiration, elevation of the bronchus by midesophageal tumors pleural effusion In advanced esophageal cancer 48% of patients will have an abnormal finding albeit subtle and nondiagnostic . - abnormal azygoesophageal line, - widened mediastinum - posterior tracheal indentation or mass, - widened retrotracheal stripe, and - compression, displacement, or irregularity of the tracheal air column. 5/5/2021 14 By Abdulmenan Abduljelil

15. ● Barium Swallow Usually, the first diagnostic method over endoscopy if the etiology of dysphagia is potentially not malignant It is a low risk, expedient study of the esophageal - mucosa, - luminal distensibility , - motility, and - any anatomic pathology, It is also a safe contrast agent to use when a TEF is suspected. The positive predictive value for detection of esophageal cancer is 42%. Benign strictures typically have symmetric areas of narrowing with smooth contours and tapered proximal and distal margins Malignant strictures typically have asymmetric narrowing with abrupt, shelf-like margins , and irregular contours with nodular or ulcerated mucosal surfaces. 5/5/2021 15 By Abdulmenan Abduljelil

16. 5/5/2021 16 By Abdulmenan Abduljelil

17. ☻Endoscopy Endoscopy remains the method of choice for the confirmation of esophageal cancer Usually diagnostic and therefore the first choice for investigation of dysphagia The location of the lesion, degree of obstruction, and longitudinal as well as circumferential extent of the lesion Biopsy and cytologic smears should be performed routinely for all visible lesions. The biopsy specimen should be taken from the edge of the lesion and not from the necrotic center. With multiple biopsy specimens, a positive tissue diagnosis is obtained in 95% of tumors. In patients with early carcinoma identified by surveillance, the endoscopic changes are subtle and may be difficult to recognize. Changes include mucosal erosion, focal congestion, and roughness of the mucosa. A small nodule, ulcer, or even a small tumor mass may be seen. 5/5/2021 17 By Abdulmenan Abduljelil

18. ☻ Bronchoscopy Necessary in carcinoma of cervical and the upper or middle thirds of the thoracic esophagus. Important in the evaluation of possible tracheal or bronchial invasion Patients with infracarinal bulky tumors or subcarinal LAP on CT should undergo bronchoscopy to evaluate for carinal involvement. Bronchoscopic findings may range from Simple bulging, loss of striations, bulging with fixation of the posterior wall of the trachea or the main bronchi frank tumor invasion, or the presence of a fistula The carina may also appear widened owing to metastatic disease to the subcarinal nodes 5/5/2021 18 By Abdulmenan Abduljelil

19. ☻Endoscopic Ultrasound It is the modality of choice for T staging EUS can assess the depth of penetration of the primary tumor is able to detect local, perigastric , and celiac lymph nodes. Although the overall accuracy of T staging is reported to range from 72% to 84% With respect to nodal staging, EUS has the highest sensitivity with pooled sensitivity of 80% as compared to PET-CT( 57%) and CT (50%) 5/5/2021 19 By Abdulmenan Abduljelil

20. ☺ CT Scan of chest and abdomen Important studies in the initial evaluation of esophageal carcinoma to determine: - the local extent of the tumor, - the relationship to adjacent structures and - distant metastases CT is generally not useful for determining T status, although preservation of fat planes suggests that the tumor is limited to the esophagus without invasion of adjacent structures Measurements of esophageal wall thickness greater than 5 mm are abnormal T1 and T2 lesions generally show an esophageal mass thickness between 5 and 15 mm, and T3 lesions show a thickness greater than 15 mm T4 lesions show invasion of contiguous structures on CT. 5/5/2021 20 By Abdulmenan Abduljelil

21. Aortic invasion is suggested by >90 degrees of contact but this is not definitive. Invasion of the pericardium is difficult to detect although obliteration of the intervening fat planes is suggestive. Mediastinal nodes >10 mm in diameter in the short axis should be classified as pathologic and that subdiaphragmatic nodes >8mm in diameter should be considered abnormal. The accuracy of CT in diagnosing mediastinal invasion has been reported in the range of 59% to 82%. Sensitivity for detecting abnormal lymph nodes (>1 cm) is *34% to 61% in the mediastinum and *50% to 76% in the abdomen, although false-positive rate may be as high as 25%. It is less helpful in the staging of cervical eso or GEJ CT may not be as sensitive for detecting disease in the celiac region. For metastatic disease, CT has a sensitivity of 70% to 80% for identifying metastases >2 cm 5/5/2021 21 By Abdulmenan Abduljelil

22. 5/5/2021 22 By Abdulmenan Abduljelil

23. ☺ Magnetic Resonance Imaging ( MRI) Offers an alternative to CT Like CT, MRI is highly accurate for detecting distant metastases especially to the liver Determining advanced local spread (T4). useful in evaluation of airway, pericardial, or aortic invasion particularly in coronal or sagittal views appears to be as sensitive as CT in predicting mediastinal invasion. it is less reliable in defining early infiltration (T1–3). 5/5/2021 23 By Abdulmenan Abduljelil

24. ☺ Positron Emission Tomography 18F-FDG PET is a useful adjunct to conventional radiographic staging. It is very sensitive for identification of primary esophageal cancer in 97% of cases compared to 81% with CT PET improves staging PET can detect 15% to 20% additional metastases compared with CT scan PET-CT is useful for detection of nodal metastases, particularly nodes distant from the primary tumor. May be used to measure the biologic activity of a tumor and thereby assess response to neoadjuvant therapy FDGPET has been reported to be useful in detecting multiple primary cancer, 5/5/2021 24 By Abdulmenan Abduljelil

25. *PET/CT has been used to differentiate benign from malignant esophageal disease * Current guidelines recommend PET for locally advanced esophageal cancer (PET) scan reveals a middle esophageal primary tumor ( arrow ) and a positive upper mediastinal lymph node ( arrowhead ) Esophageal cancers have eccentric, focal uptake in the esophageal wall, benign disease is associated with - luminal uptake or - concentric,diffuse,homogeneous mural uptake 5/5/2021 25 By Abdulmenan Abduljelil

26. ☺Abdominal Ultrasound Often performed instead of CT to diagnose liver or celiac lymphatic metastasis ☺ Thoracoscopy and laparoscopy These procedures are generally more accurate in determining nodal status than noninvasive techniques Are helpful in evaluating the extent of local invasion and detecting metastatic disease Direct visualization and the ability to document disease histologically may add benefit when the nature of enlarged LNs remote from the cancer cannot be determined When advanced imaging systems (PET and high-resolution spiral CT) are not available Laparoscopy is useful for identifying peritoneal metastases with 96% sensitivity and is recommended for gastric and GEJ cancers Krasna and colleagues48 found thoracoscopy to be accurate in 93% and laparoscopy in 94% of patients in identifying metastatic disease. Six cases of unsuspected celiac nodal disease were identified in 19 patients despite preoperative CT and EUS 5/5/2021 26 By Abdulmenan Abduljelil

27. Staging Of Esophageal Cancer Accurate staging is essential for treatment selection The stage at diagnosis is the most important prognostic factor One needs to determine if the disease is -disseminated (any T, any N, M1) -locally advanced (T1–3, N1), -confined to the esophagus, (T1–T2, N0) -very early tumors confined to the mucosa ( Tis , T1a, intramucosal cancer 5/5/2021 27 By Abdulmenan Abduljelil

28. treatment of esophageal cancer General Approach to Esophageal Ca Mx Therapy of esophageal cancer is dictated by stage of the cancer at the time of diagnosis The selection of a curative vs. a palliative operation depends the location of the tumor the patient’s age and health the extent of the disease, and preoperative staging early stage esophageal ca confined to the esophagus, (T1–T2, N0) locally advanced (T1–3, N1), disseminated (any T, any N, M1) 5/5/2021 28 By Abdulmenan Abduljelil

29. LOCATION OF THE TUMOR 1. Cervical esophagus tumor Almost always SCC Early invasion of the larynx, great vessels, or trachea Frequently unresectable Radical surgery, including esophagolaryngectomy may occasionally be performed Stereotactic radiation with concomitant chemotherapy is the most desirable treatment . 5/5/2021 29 By Abdulmenan Abduljelil

30. 2. middle third esophageal cancer are most commonly SCC are frequently associated with LN metastasis generally individuals with midthoracic cancer and abdominal LN mets are incurable with surgery LN+ cancers or T3 cancers warrant treatment with neoadjuvant CRT followed by resection T1 and T2 cancers without LN metastases are treated with resection only 3. Tumors of the lower esophagus and cardia are usually adenocarcinomas . unless preoperative and intraoperative staging clearly demonstrate an incurable lesion, resection with a LND should be performed 5/5/2021 30 By Abdulmenan Abduljelil

31. AGE Resection for cure of carcinoma of the esophagus in a patient older than 80 years is rarely indicated because of the additional operative risk and the shorter life expectancy. Minimally invasive surgery may reduce the morbidity and mortality associated with open two- or three-field esophagectomy . NUTRITIONAL STATUS Profound weight loss is associated with a much higher rate of complications and mortality Malnourished patients generally have locally advanced esophageal cancer - consider the placement of a feeding tube before the beginning of induction chemoradiation therapy. 5/5/2021 31 By Abdulmenan Abduljelil

32. CARDIOPULMONARY RESERVE Patients undergoing esophageal resection should have sufficient cardiopulmonary reserve to tolerate the proposed procedure. FEV1 Echo and dipyridamole thallium imaging provide accurate information on wall motion, EF, and myocardial blood flow preoperative coronary angiography. Any patient with a forced expiratory volume in 1 second of <1.25 L is a poor candidate for thoracotomy A resting ejection fraction of <40%, particularly if there is no increase with exercise, is an ominous sign Most individuals who can climb three flights of stairs without stopping will do well with two-field open esophagectomy 5/5/2021 32 By Abdulmenan Abduljelil

33. Management based on Clinical staging Clinical factors that indicate an advanced stage of eso.ca and exclude surgery with curative intent are recurrent nerve paralysis, Horner’s syndrome, persistent spinal pain, paralysis of the diaphragm, fistula formation, and malignant pleural effusion a weight loss >20%, and loss of appetite Advanced image Findings that make surgical cure unlikely *tumor >8 cm in length, *abnormal axis of the esophagus on a barium radiogram, * >4 enlarged LNs on CT, 5/5/2021 33 By Abdulmenan Abduljelil

34. Summary of management algorithm 5/5/2021 34 By Abdulmenan Abduljelil

35. 5/5/2021 35 By Abdulmenan Abduljelil

36. MODALITIES OF TREATMENT Early stage esophageal ca ( Cis /HGD, and stage IA(T1N0M0G1/2), IB(T1N0M0G3, T2N0M0G1/2 ) 1.Endoscopic Treatment EMR and endoscopic ablative therapies Indications all nodules identified in a field of BE Cis (HGD) tumors that are limited to the mucosa (stage T1aNO) well- and/or moderately differentiated SCC of m1 or m2 infiltration with no evidence of LN mets . Relative indication: m3 and sm1 tumors, because of the fairly frequent nodal metastases Patients in whom there is a question of depth of mucosal invasion should be considered for a diagnostic EMR 5/5/2021 36 By Abdulmenan Abduljelil

37. As long as the tumor is found to be confined to the mucosa and all margins are negative, the resection is complete Complications of EMR include -bleeding (which is usually minor), -perforation (which can be prevented by adequate submucosal saline injection and can be treated sometimes with hemoclipping ), - stenosis (tends to occur when the lesion is large) 2.Esophagectomy Indications Positive margin involvement of the submucosa (T1b), tumor size >2 cm, or poor differentiation. (Stage IB,T1N0M0 G3) **surgery alone is curative for stage I esophageal cancer 5/5/2021 37 By Abdulmenan Abduljelil

38. Treatment of Locally advanced Eso . Ca (Stage II & III) 1.Surgery Alone Deep submucosal lesions have approximately a 30% risk of regional LAP and transmural tumors carry risk of 80% -100% Results with surgery alone in patients with regional LN metastasis are relatively poor There are many available techniques for performing esophageal resection, Most often this choice is based on surgeon preferences and/or tumor location. Locally advanced tumors with involvement of the distal esophagus and proximal stomach treated by Ivor -Lewis esophagectomy A lymphadenectomy is easily performed in two fields and Negative margins can be obtained on the stomach with less concern for gastric necrosis. 5/5/2021 38 By Abdulmenan Abduljelil

39. Surgical resection has a therapeutic role in the treatment of local and locoregional disease Great controversy remains over the extent of the resection necessary and over the value and extent of lymphadenectomy It is recommended that a minimum of a 5-cm margin, and preferably a 10-cm margin, be taken on the esophagus. Multiinstitutional reports that have focused on specific subsets of patients in stages IIb to III patients who have undergone complete lymphadenectomy : have improved survival can still look forward to excellent locoregional control. Proponents of radical resection with more extensive surgical procedures reported increased survival rates and excellent locoregional control, 5/5/2021 39 By Abdulmenan Abduljelil

40. Higher LN ratio among patients with node-positive esophageal cancer was demonstrated to be associated with significantly worse survival Current NCCN guidelines suggest at least 15 LNs be evaluated Even in patients with node-negative disease, the number of negative lymph nodes correlated with survival Node-negative eso ca patients with 18 or more LNs demonstrated a 20% improvement in 5-year disease-specific survival compared to node-negative patients with 10 or less lymph nodes evaluated a higher number of negative LN is independently associated with higher disease-specific survival Results of Surgical Therapy 5/5/2021 40 By Abdulmenan Abduljelil

41. 2.Neoadjuvant Radiotherapy Preop radiotherapy followed by surgery Compared to surgery alone it reduces the mortality rate by 11% and improves the absolute survival at 2 years from 30% to 34%. Currently, neoadjuvant radiation alone prior to surgery is recommended only for Clinical trials Clinical circumstances that preclude combined CRT eg prior chemotherapy 5/5/2021 41 By Abdulmenan Abduljelil

42. 3.Neoadjuvant chemotherapy preoperative chemotherapy followed by surgery Survival benefit versus surgery alone. The largest enrolled study was from the UK involved 802 patients, with mixed adenocarcinoma and SCC Survival at 5 years in the combined-modality arm was 23% versus 17% in the surgery-alone cohort. Gebski et al. reviewed eight trials Included 1,724 patients with both squamous cell and adenocarcinoma showed a significant reduction in mortality for neoadjuvant chemotherapy (the survival benefit was exclusive to adenocarcinoma .) 5/5/2021 42 By Abdulmenan Abduljelil

43. 4. Neoadjuvant Chemoradiotherapy Chemoradiation followed by surgery is the standard treatment option for patients with locally advanced esophageal cancer the Dutch CROSS trial Published in 2012, 366 patients with resectable esophageal or junctional cancers to receive either surgery-alone or weekly administration of carboplatin and paclitaxel with concurrent radiation therapy (41.4 Gy in 23 fractions) administered over 5 weeks, followed by resection. median follow-up of 45 months, preoperative chemoradiation was found to improve median overall survival from 24 months in the surgery-alone group to 49.4 months preoperative chemoradiation improved the rate of R0 resections pathologic complete response was noted in 29% of chemoradiation pts. 5/5/2021 43 By Abdulmenan Abduljelil

44. 5. Adjuvant Chemotherapy The efficacy of adjuvant chemotherapy for LN+ esophageal adenocarcinoma has not been proven in RCT -but continues to be recommended as the standard of care in the NCCN guidelines Postop . therapies for patients with SCC are considered only for positive resection margins (R1 or higher) - pts with SCC who undergo R0 resection, regardless of nodal status, are designated for surveillance only. *Published in 1996, a Japanese Oncology Group (JCOG) study by Ando randomized 205 patients with scc to surgery alone or surgery followed by cisplatin and vindesine . There was no statistical significance in 5-year survival rates between the two groups 5/5/2021 44 By Abdulmenan Abduljelil

45. A follow-up study by the same group in 2003 evaluated postoperative cisplatin and 5-FU , in patients with squamous cell cancer only, and  found a modest improvement in survival with the adjuvant therapy group (61% vs. 52%) that did not reach statistical significance. ** A more recent JCOG study, published in 2012, compared neoadjuvant to adjuvant chemotherapy in patients with esophageal SCC and found a significant survival benefit to adjuvant chemotherapy, albeit less than the benefit accrued by the preoperative group. Overall 5-year survival rates were 55% in the preoperative group and 43% in the postoperative therapy group . 5/5/2021 45 By Abdulmenan Abduljelil

46. 6. Definitive Chemoradiation In patients ineligible for surgery In the context of combined CRT as definitive treatment for esophageal cancer chemotherapy controlls micrometastatic disease, thought to sensitize tumor cells to radiation Cochrane Database review of 19 randomized trials, published in 2006 by Wong and Malthaner comparing CRT to radiation alone ,  There was a reduction in mortality and in local recurrence rates, but these came at the cost of significant toxicities. An ECOG trial evaluated mitomycin -C and 5-FU with radiation compared to radiation alone  noted a median survival of 14.5 months compared to 9.2 months in the radiation-alone group 5/5/2021 46 By Abdulmenan Abduljelil

47. SCC are increasingly being treated with definitive chemotherapy and radiation, esp. those located in the cervical and very proximal esophagus Treatment for SCC tumors located in the mid-distal esophagus is often individualized Consideration for resection , based on presence of disease and high-risk recurrence areas -non responding pts and -those with tumor behind the airway 5/5/2021 47 By Abdulmenan Abduljelil

48. Treatment of metastatic eso ca. (stage IVA, IVB) 1.Palliative Chemotherapy Pts who present with nonregional LN involvement or other distant metastatic disease are candidates for palliative chemotherapy. On occasion, patients with stage IV disease whose tumor burden is systemically controlled become candidates for consolidative local regional therapy ( chemoradiation ) Dysphagea Grades I to III often can be managed with radiation therapy, usually in combination with chemotherapy. When surgical resection is not anticipated in the future, this is termed definitive chemoradiation therapy and usually is palliative. Radiation dose is increased from 45 Gy to 60 Gy administered over 8 wks, rather than the 4 wks given for induction CRT 5/5/2021 48 By Abdulmenan Abduljelil

49. 2. Salvage Esophagectomy esophagectomy performed after failure of definitive radiation and chemotherapy. In 20% of patients, a complete response to CRT will not only palliate the symptoms but will also leave the patient with undetectable cancer of the esophagus. some of these patients are truly cured, cancer will recur in many either locally or systemically 1-5 years following definitive chemoradiation . After a 12-month wait from initial treatment and no other sites of tumor detectable except the esophagus, some of these patients may be candidates for salvage esophagectomy . The most frequent scenario is one in which distant disease (bone, lung, brain, or wide LN metastases) renders the patient nonoperable at initial presentation Then, systemic chemotherapy, usually with radiation of the primary tumor, destroys all foci of metastasis, as demonstrated by CT and CT-PET, but the primary remains present and symptomatic 5/5/2021 49 By Abdulmenan Abduljelil

50. 3.Palliative Surgery palliative surgical resections, is generally not recommended Candidates for surgical palliation uncontrolled bleeding or perforation expected to have a significant life span despite metastatic or advanced esophageal cancer If feeding access is desirable, a laparoscopic jejunostomy is usually the procedure of choice. 4. Non-Operative Palliation mechanical stents for perforation or trachea–esophageal fistula radiation for local control of bleeding For individuals with dysphagia grades IV and higher, the mainstay of therapy is indwelling esophageal stents 5/5/2021 50 By Abdulmenan Abduljelil

51. Approaches for Esophageal Resection Surgical resection remains the mainstay treatment for pts with localized eso ca It is justified only when acceptably low morbidity and mortality rates can be achieved The results of surgical resection are dependent on many factors and are mainly related to the following: 1. Selection of appropriate patients for resection and optimization of the pts’ physiologic status before surgery 2. Choice of surgical techniques and their execution 3. Perioperative care There are many available techniques for performing esophageal resection, Most often this choice is based: on surgeon preferences and/or tumor location 5/5/2021 51 By Abdulmenan Abduljelil

52. Principles Complete resection (R0) is the ultimate goal of esophagectomy for cancer Optimal preoperative staging and individual case presentation and discussion at the multidisciplinary tumor board In cases of suspicious lymph nodes ( cN +) and/or transmural tumor extension (cT3-4), a multimodality treatment plan including induction chemo ± radiotherapy is commonly used in most centers today. Positive LN is not necessarily a contraindication for surgery if the metastatic LNs are deemed resectable and within the region of the primary tumor. Resection is ill-advised when a macroscopically incomplete resection is expected, typically due to invasion of adjacent structures and/or non- resectable metastases Absolute contraindications for esophagectomy include local tumor invasion of non- resectable neighboring structures (T4), carcinomatosis peritonei , hematogenous metastases involving solid organs, or non- resectable metastatic lymph nodes. 5/5/2021 52 By Abdulmenan Abduljelil

53. Extent Of Resection The radical en bloc resection aims at performing a wide as possible peritumoral with an en bloc LN resection of the middle and distal thirds of the posterior mediastinum Standard resection Two-Field Lymph Node Dissection Incorporates a wide local exision of the primary tumor plus lymphadenectomy of in the chest and abdomen In the chest it includes Lymph nodes of the entire posterior mediastinum , the subcarinal nodes and Lymph nodes along the left RLN and brachiocephalic trunk. In the abdomen it includes the LNs along the celiac trunk, common hepatic and splenic arteries, as well as the lesser gastric curvature and lesser omentum . 5/5/2021 53 By Abdulmenan Abduljelil

54. Three-Field Lymph Node Dissection About 20% of patients with a distal eso . tumor present with metastasis in the cervical region, the three-field LND developed This incorporates - removal of the thoracic and - abdominal nodes, - the cervical lymph nodes Typically this includes the paraesophageal nodes, the nodes lateral to the carotid vessels, and the supraclavicular nodes 5/5/2021 54 By Abdulmenan Abduljelil

55. Since 1994 lymph node dissection in the chest has been defined as: standard -lower periesophageal LNs & - subcarinal nodes extended - including some upper mediastinal nodes, i.e., right paratracheal nodes total thoracic lymph node dissection - including the uppermost mediastinal nodes, i.e., left and right paratracheal and aortopulmonary window nodes a classic two-field lymphadenectomy should include at least the periesophageal LNs subcarinal nodes and preferably also the node at the aortopulmonary window and the right paratracheal nodes. 5/5/2021 55 By Abdulmenan Abduljelil

56. Surgery For Carcinoma Of Cervical Esophagus pharyngolaryngoesophagectomy (PLE) a one-stage, three phase operation involves cervical and abdominal incisions and a thoracotomy . Tumors involving the hypopharyngeal and upper cervical esophageal region were resected together with the whole esophagus the stomach was delivered via the posterior mediastinum to the neck for pharyngogastric anastomosis . A terminal tracheostome was constructed. The thoracotomy was later replaced by transhiatal esophageal mobilization. Thoracoscopic esophageal mobilization has become another, and our preferred, alternative. 5/5/2021 56 By Abdulmenan Abduljelil

57. options for reconstruction after resection for tumors confined to the proximal portion of the cervical esophagus, with sufficient distal margin, free jejunal interposition grafts and deltopectoral or pectoralis major myocutaneous flaps PLE is associated with significant morbidity and mortality The need to sacrifice the larynx makes surgical resection an unattractive option, and - upfront chemoradiotherapy is preferred by many 5/5/2021 57 By Abdulmenan Abduljelil

58. Surgery For Intrathoracic and Abdominal Esophageal Cancer Currently, there are several surgical approaches to adenocarcinoma of the distal esophagus and EGJ right-sided abdominotransthoracic approach with anastomosis high in the chest ( Ivor Lewis ) or right-sided abdominotransthoracic approach with anastomosis in the neck ( McKeown , aka 3-hole resection), a left-sided abdominotransthoracic approach with anastomosis in the chest ( Sweet ) or a left-sided abdominotransthoracic approach with anastomosis in the neck ( Belsey ), a transhiatal resection with anastomosis in the neck ( Orringer ), the minimally invasive esophagectomy (MIE) 5/5/2021 58 By Abdulmenan Abduljelil

59. 1. Ivor Lewis (En Bloc) Esophagectomy It is a two-stage procedure Consists of - an upper midline laparotomy for gastric mobilization and tubularization , - a right thoracotomy for esophageal resection and reconstruction Radical lymphadenectomy is performed in the upper abdomen and chest extensive LND in and about the celiac access and its branches, extending into the porta hepatis and along the splenic artery to the tail of the pancreas. All LNs are removed en bloc with the lesser curvature of the stomach. Unless the tumor extends into the stomach, reconstruction is performed with a greater curvature gastric tube Allows greater removal of LNs and periesophageal tissues diminishes the chance of a positive radial margin and LN recurrence 5/5/2021 59 By Abdulmenan Abduljelil

60. Techniques The patient is positioned supine for the abdominal portion of the operation and in a true lateral position for the thoracic portion, using a standard lateral or a posterolateral thoracotomy Use of an epidural catheter is appropriate for postoperative analgesia Use of a double lumen tube for lung isolation is critical The initial approach is through a laparotomy , consisting of either an upper midline incision or an inverted “V” (chevron) incision Exploration of the abdomen is performed the gastric dissection is performed after the ability to accomplish a complete resection is confirmed. The greater curve is mobilized preserving the right gastroepiploic vessels The gastrohepatic ligament is divided, taking care to ensure that an aberrant left hepatic artery is not sacrificed. The peritoneum overlying the esophagus is divided, freeing the esophagus from the crura bilaterally 5/5/2021 60 By Abdulmenan Abduljelil

61. The attachments of the esophagus to the retroperitoneum are divided and the esophagus is encircled with an umbilical tape or Penrose drain to permit downward traction on the esophagus during subsequent dissection. The retroperitoneal attachments to the stomach are divided The gastric tubularization is performed using several linear staplers, starting from the gastric fundus down to the place on the small curvature where the right gastric artery has been ligated . The staple line is placed such that it leaves a gastric tube of 4 to 5 cm in width 5/5/2021 61 By Abdulmenan Abduljelil

62. By resecting the lesser curvature, all lymphatic tissue in this area is removed. A lymph node dissection along the splenic artery, common hepatic artery, and celiac axis is performed. This also can be done en bloc with the dissection of the left gastric artery. If desired, a gastric emptying procedure is performed ( pyloromyotomy or pyloroplasty ) Following closure of the abdominal incision, the patient is placed in the left lateral decubitus position and an anterolateral thoracotomy is performed The chest is opened through the 5th or 6th interspace , depending on the location of the tumor and the habitus of the patient The right lung is selectively deflated and retracted anteriorly . First , the azygos vein is dissected, ligated , and transected , as well as the underlying intercostobronchial artery. The mediastinal pleura anterior to the esophagus is opened widely from the azygos vein to the top of the chest 5/5/2021 62 By Abdulmenan Abduljelil

63. The proximal esophagus is dissected circumferentially and looped with an umbilical tape. The dissection is carried cephalad toward the apex of the chest Similar dissection of the esophagus is achieved by encircling it with a tape distally from the distal pole of the tumor. Dissection of the esophagus proceeds inferiorly, encompassing all tissue between the aorta and pericardium, including all periesophageal and subcarinal nodes. Both vagal nerves are transected A further LND is performed along the left and right paratracheal spaces, along the aortopulmonary window, and along the right recurrent nerve at the level of the brachiocephalic trunk A suitable point at least 5 cm above the tumor is chosen for transecting the esophagus. After transection , a frozen section must be obtained of the proximal resection margin to confirm the absence of tumor extension in the suture line. 5/5/2021 63 By Abdulmenan Abduljelil

64. At this point, the gastric tube can be pulled up into the chest cavity Esophagogastrostomy done (a circular stapler or hand-sewn anastomosis ) 5/5/2021 64 By Abdulmenan Abduljelil

65. For GEJ cancers extending significantly into the gastric cardia or fundus , - the proximal stomach is removed, - and reconstruction is performed with an isoperistaltic section of left colon between the upper esophagus and the remnant stomach, or - the colon is connected to a Roux-en-Y limb of jejunum, if total gastrectomy is necessary. In most cases pleural flap used to cover the anastomosis to protect the chest cavity from anastomotic leakage. The thoracic cavity is usually drained using a 36F chest drain placed in the paraspinous position . The chest wall is closed in layers. 5/5/2021 65 By Abdulmenan Abduljelil

66. Postoperative care Fluid balance and oxygen saturation should be closely monitored, Oxygen supplementation is mandatory. Fluid restriction is used to avoid cardiac and respiratory complications, especially in patients having neoadjuvant therapy. It is also vital to maintain adequate and balanced nutrition during the early postoperative period Thrombosis prophylaxis is continued by subcutaneous LMWH injections prophylactic antibiotics given for 2 days . NGT is kept in place to prevent aspiration On day 5, a contrast study is performed to evaluate the integrity of the anastomosis . If no leak is visualized, oral feeding is started The chest drain will be removed when the output is <200 mL of fluid 5/5/2021 66 By Abdulmenan Abduljelil

67. Complications Because this is the most radical of dissections, complications are most common, including pneumonia, respiratory failure, atrial fibrillation, chylothorax , anastomotic leak, conduit necrosis, gastrocutaneous fistula, and, if dissection is too near the RLN, hoarseness will occur with an increased risk of aspiration. Tracheobronchial injury resulting in fistulas between the bronchus and conduit may also occur 5/5/2021 67 By Abdulmenan Abduljelil

68. 2. The McKeown approach A three-phase esophagectomy In this procedure a right thoracotomy is first carried out to mobilize the thoracic esophagus together with LND This is followed by abdominal and neck incisions for the mobilization of the esophageal substitute placing the anastomosis in the neck. Has the advantage of placing the anastomosis in the neck where leakage is unlikely to create a severe systemic consequence The esophagus is dissected along its length to include division of the azygos vein and harvesting of the LNs in the upper, middle, and lower posterior mediastinum . 5/5/2021 68 By Abdulmenan Abduljelil

69. Hilar , and posterior mediastinal nodes are all removed The thoracic duct is divided at the level of the diaphragm and removed with the specimen. Upper abdominal lymphadectomy A transverse cervical incision Dissection between the SCM and the anterior strap muscles allows access to the cervical esophagus The esophagus and proximal stomach is then pulled up into the neck with the gastric conduit Cervical anastomosis is then performed. 5/5/2021 69 By Abdulmenan Abduljelil

70. 3. Sweet Thoracotomy Left Thoracoabdominal incision Through a left thoracotomy and incision in the diaphragm, both the esophagus and stomach could be mobilized and resection carried out; The stomach is then delivered into the chest for anastomosis , either below or above the aortic arch. This is generally more suitable for cancer of the distal esophagus where an adequate resection margin is obtained below the aortic arch. This method is most popular in China The thoracoabdominal incision provides excellent access to the abdomen In addition, with an upward paravertebral extension of the incision and Sweet’s double-rib resection, one can reach almost any lesion of the intrathoracic esophagus. 5/5/2021 70 By Abdulmenan Abduljelil

71. Techniques The patient is positioned in the right lateral decubitus position The initial step is an exploration of the abdomen through the medial portion of the incision. Aim the medial aspect at a point halfway between the xiphoid and umbilicus The abdominal portion of the incision permits inspection of the liver, palpation of the celiac nodes, and further evaluation of the stomach. With no metastatic disease identified, the incision is carried into the chest over the 7 th or 8 th rib 5/5/2021 71 By Abdulmenan Abduljelil

72. Dissection begins in the chest, freeing the esophagus and harvesting all adjacent lymph nodes. The descending aorta is completely bared by division of the aortoesophageal branches. The esophagus is encircled after the dissection is carried medially along the posterior aspect of the mediastinum up to the level of the left main stem bronchus, away from the proximal tumor margin 5/5/2021 72 By Abdulmenan Abduljelil

73. 4. Trans- hiatal Approach Particularly applicable to tumors of distal esoph . and EGJ The thoracic part of the esophagus is mobilized by blunt and often blind dissection through the enlarged hiatus The mobilized stomach is then delivered to the neck and anastomosed to the cervical esophagus Advocated especially for distal esophageal tumor or early-stage tumors of other parts of the esophagus This operation is the quickest to perform in experienced hands With respect to complications and recovery lies in an intermediate position between MIE and the Ivor Lewis procedure 5/5/2021 73 By Abdulmenan Abduljelil

74. Advantages a short operative duration lower incidence of pulmonary complications avoidance of postthoracotomy pain. The stomach is preferred for reconstruction and is anastamosed to the remaining cervical esophagus. This can be achieved via the esophageal bed (the so-called prevertebral route) or via the retrosternal route The main drawbacks of this approach are inability to perform an extensive LND and risk of injury to the great vessels and main airways with T3 or greater ** Pulmonary and cardiac function should be assessed. ** ignificant carotid artery stenosis and coronary artery disease should be ruled out. 5/5/2021 74 By Abdulmenan Abduljelil

75. Operative Technique The operation begins with a median laparotomy , Incision extending from the xiphoid process to just below the umbilicus. The abdominal cavity is inspected and palpated in search of distant mets Mobilizing the left lobe of the liver, - The left triangular hepatic ligament is divided The esophageal hiatus can be inspected and tumors of the EGJ can be assessed for invasion of adjacent organs. Subsequently, the stomach is mobilized. The esophagus is freed in the hiatus, and if necessary, a surrounding cuff of diaphragm can be included in the resection specimen 5/5/2021 75 By Abdulmenan Abduljelil

76. 5/5/2021 76 By Abdulmenan Abduljelil

77. The NGT is positioned along the greater curvature of the stomach with its tip near the pylorus and is used as a handhold on the stomach. The abdominal esophagus is dissected from its crural attachments with electrocautery , encircled, and elevated on a Penrose drain The greater curvature of the stomach is mobilized using a harmonic scalpel, taking great care to avoid injury to the gastroepiploic arcade The gastric fundus is mobilized using a harmonic scalpel to divide the short gastric vessels 5/5/2021 77 By Abdulmenan Abduljelil

78. A generous Kocher maneuver is performed. The serosa overlying the anterior wall of the pylorus is incised with electrocautery , avoiding the great pyloric vein of Mayo A complete pyloromyotomy is performed using straight Mayo scissors or a #15 blade. Alternatively, a formal Heineke-Mikulicz pyloroplasty may be performed Attention is turned to the diaphragmatic hiatus - peritoneal reflection and phrenoesophageal ligament are taken with electrocautery dissection, completely mobilizing the esophagus in the hiatus. Transhiatal exposure is achieved by manual retraction using the hooked handles of two narrow Deaver retractors 5/5/2021 78 By Abdulmenan Abduljelil

79. The periesophageal fatty tissues, the left and right parietal pleura, and if needed the pericardium are included in the surgical specimen. This procedure can be advanced at least as far as the inferior pulmonary veins 5/5/2021 79 By Abdulmenan Abduljelil

80. Mobilization of the intrathoracic esophagus proceeds cephalad while maintaining downward traction on the stomach. Blunt manual dissection is performed along the anterior and posterior aspects of the thoracic esophagus The entire thoracic esophagus completely mobilized, Attention is turned to the left neck, where an incision is made along the anterior border of the SCM and deepened through the platysma 5/5/2021 80 By Abdulmenan Abduljelil

81. The more proximal and unmobilized part of the esophagus is bluntly mobilized or stripped, using a vein stripper through a neck incision Next, the central tendon of the right hemi-diaphragm is incised, thus opening the lower mediastinum 5/5/2021 81 By Abdulmenan Abduljelil

82. After the intra-abdominal dissection is complete, the lesser curvature is resected and a neoesophagus is created, by fashioning a narrow 3-4 cm wide gastric tube 5/5/2021 82 By Abdulmenan Abduljelil

83. Creation of the Anastomosis and Feeding Jejunostomy Care is taken to avoid leaving an excessive length of cervical esophagus. Every effort is made to ensure that the anastomosis remains both tension free and above the level of the thoracic inlet The nasogastric tube is advanced beyond the anastomosis into the stomach and positioned with its tip at the level of the diaphragmatic hiatus 5/5/2021 83 By Abdulmenan Abduljelil

84. POSTOPERATIVE CARE The patient typically is extubated in the operating room at the end of the procedure. An upright chest radiograph is obtained in the recovery room - to verify the position of the nasogastric tube and central line and - to rule out pleural effusion or pneumothorax To avoid aspiration, the head end of the bed is elevated (reverse Trendelenburg ), maintaining an angle of at least 30 degrees at all times. Fastidious maintenance of patency of the nasogastric tube is critical to ensure that the stomach is kept empty Aggressive thromboprophylaxis is maintained with pneumatic intermittent calf compression boots and subcutaneous heparin The Penrose drain is removed from the neck on the first postoperative day, after bile leak and hemorrhage have been excluded. 5/5/2021 84 By Abdulmenan Abduljelil

85. No oral intake of any kind is permitted initially. Tube feedings may be started via the jejunostomy when appropriate and are increased gradually to the goal rate After 6 days without any oral intake, ice chips are permitted sparingly. 7 th day postoperatively, a fluoroscopic swallow study is performed with the nasogastric tube in place. In the absence of a leak, the nasogastric tube is removed, and the patient is allowed to continue taking ice chips orally. If there are no signs or symptoms of leak or infection, the patient’s diet is advanced to clear fluids on the first morning after a normal barium swallow. Full fluids are permitted the next day. When tolerating soft solids orally, the patient is discharged from the hospital When caloric intake goals are met orally, the jejunostomy tube is removed 5/5/2021 85 By Abdulmenan Abduljelil

86. 5. Minimally Invasive Esophagectomy The advent of laparoscopy and thoracoscopy in the 1980s opened the door to the possibility of a minimally invasive approach to esophageal surgery Indications for the minimally invasive approach for esophagectomy include Barrett esophagus with high-grade dysplasia, end-stage achalasia , esophageal strictures, and esophageal cancer. (<T4) Downstaged cancer with neoadjuvant chemoradiation Operative approaches to MIE have varied from a 3-hole modified McKeown to the Ivor Lewis approach MIEx may be performed with an the anastomosis stapled in the high thorax ( twofield ) Or anastomosis created in the neck (three-field) 5/5/2021 86 By Abdulmenan Abduljelil

87. A. Minimally Invasive Ivor Lewis approach (Two field MIEx ) Esophagogastroscopy is performed in all patients to confirm the location of the tumor and the suitability of the stomach for tubularization . For midesophageal tumors, a bronchoscopy is also indicated. The patient is intubated with a double-lumen ETT at the start of the case. Both lungs are ventilated during the abdominal dissection. The right lung is isolated during the thoracic dissection to provide adequate visualization and mobilization of the esophagus The patient is placed supine for laparoscopy Five ports are used for the gastric mobilization 5/5/2021 87 By Abdulmenan Abduljelil

88. A 10-mm port is placed rt of midline in the epigastrium , slightly below the midpoint b/n the xiphoid process and the umbilicus A 5-mm port is placed to the left of midline atthe same level as the original port. - A 5-mm, 30-degree camera is placed through this port Additional 5-mm ports are placed at the left subcostal margin and the right subcostal margin. A 5-mm port is placed in the right flank to support a liver retractor. - A self-retaining retractor is used to elevate the left lobe of the liver and expose the hiatus 5/5/2021 88 By Abdulmenan Abduljelil

89. The gastrohepatic ligament is divided to expose the right crus . The esophagogastric junction is freed from the hiatus by dissection up the right crus . The phrenoesophageal ligament is taken down, and the dissection is extended to the left crus The right gastroepiploic arcade is identified, and the gastrocolic ligament is divided lateral to this arcade. Dissection is carried up along the greater curvature of the stomach, taking down the short gastric arteries. The stomach is retracted superiorly and to the right to expose the celiac vessels. Celiac and gastric nodal tissue is dissected free and left with the specimen. The lt gastric artery then is isolated and divided at the base A Kocher maneuver is performed 5/5/2021 89 By Abdulmenan Abduljelil

90. The retrogastric and duodenal attachments are carefully dissected to achieve adequate mobilization of the gastric tube The gastric tube construction based on right gastroepiploic vessels Preferable to create conduit of 4-5cm wide A pyloroplasty is performed in Heinecke-Mikulicz fashion An additional 10-mm port is placed in the RLQ to facilitate jejunostomy tube placement 5/5/2021 90 By Abdulmenan Abduljelil

91. The patient is placed in the left lateral decubitus position for thoracoscopy The right lung is isolated. Four ports are used to access the right chest . A 10-mm camera port is inserted in the AAL at the 8th interspace An additional 10-mm port is placed approximately 2 cm posterior to PAL in the 8th or 9th interspace . This is the main dissection port for the harmonic scalpel (Ethicon). A 10-mm port is placed in the fourth interspace along the AAL A fan retractor is placed through this port to provide retraction of the lung Finally, a 5-mm port is placed below the scapular tip. A fifth 5-mm port can be placed at the sixth rib, at the anterior axillary line, for suction by the assistant. 5/5/2021 91 By Abdulmenan Abduljelil

92. Dissection is begun by taking down the inferior pulmonary ligament The mediastinal pleura is dissected anteriorly along the plane between the edge of the lung and the esophagus and is resected with the specimen up to the azygos vein. The subcarinal LNs are taken en bloc with the esophagus Aortoesophageal attachments are also isolated, clipped, and divided. All surrounding soft tissue is taken with the esophagus, including the lymph node packets 5/5/2021 92 By Abdulmenan Abduljelil

93. Once the dissection is carried up to the divided azygos vein the vagus nerve is divided, and the dissection is now performed close to the esophagus Periesophageal dissection can be taken all the way up to the thoracic inlet. Once the esophagus is mobilized, the specimen and the gastric conduit are brought into the field with gentle retraction of the esophagus. the esophagus is sharply divided with endoshears , dividing the proximal esophagus and separating the specimen. The posterior inferior dissection port is increased by 2 cm and fitted with a wound protector The specimen is removed through the wound 5/5/2021 93 By Abdulmenan Abduljelil

94. The patient is then rolled into the left lateral decubitus position and, through right thoracoscopy , the esophagus is dissected and divided 10 cm above the tumor. Once freed, the specimen is pulled out through the mini- thoracotomy , and an end-to-end anastomosis stapler is introduced through the high corner of the gastric conduit and out a stab wound along the greater curvature. 5/5/2021 94 By Abdulmenan Abduljelil

95. 5/5/2021 95 By Abdulmenan Abduljelil

96. B. Minimally Invasive Mckeon Approach (Three field MIEx ) The dissection is started in the right chest with the patient in the left lateral decubitus position. Full mobilization is performed using similar port placement as described for the thoracoscopic phase of the Ivor Lewis MIE however, the dissection of the mediastinal pleura is continued up to the thoracic inlet. A Penrose drain is wrapped around the esophagus for later retrieval in the neck. The patient is placed supine and the stomach mobilized as described above. The phrenoesophageal ligament is dissected last, as entrance here can evacuate the abdominal insufflation into the right chest and out the chest tube 5/5/2021 96 By Abdulmenan Abduljelil

97. A horizontal incision is made along a cervical crease above the sternal notch and extending to the left. Dissection is carried down, and platysmal flaps are developed. Dissection is continued along the anterior border of the SCM The omohyoid muscle is divided, and gentle dissection is continued down to the prevertebral fascia. The cervical esophagus is gently retracted medially with a peanut dissector. Careful dissection performed inferiorly should open into the thoracic inlet. The Penrose drain left in the thoracic inlet at the end of the thoracoscopic portion of the surgery should be readily encountered in the neck and retracted out through the cervical wound. 5/5/2021 97 By Abdulmenan Abduljelil

98. The proximal cervical esophagus is mobilized. An auto–purse-string device ( Covidien , Norwalk, CT) is applied 2 to 3 cm distal to the cricopharyngeus , and the esophagus is divided. A 25-mm EEA stapler is used to perform the anastomosis Once the anastomosis is complete, a NGT is guided under direct vision. The gastrotomy opening is closed by stapling off the distal 5 to 6 cm of the proximal gastric tube with an Endo-GIA stapler. Attention is directed back into the abdomen. Graspers are applied to the antral area, and Gentle downward traction is applied until the cervical anastomosis dips into the neck inci sion The cervical anastomosis is irrigated, and the skin is only loosely approximated with one or two staples. 5/5/2021 98 By Abdulmenan Abduljelil

99. Complications Of 3-field MIEx the most common complication is pneumonia, the second is atrial fibrillation, and the third is anastomotic leak. the risks of injury to structures in the neck, particularly the recurrent laryngeal nerve compared to 2-field MIEx Advantages of 3-field MIEx vs 2-field MIEx Placing the anastomosis in the neck where leakage is unlikely to create a severe systemic consequence . 5/5/2021 99 By Abdulmenan Abduljelil

100. Results Of MIEx The Pittsburgh series of 1011 patients who underwent a planned MIE, the 30-day operative mortality was 1.7%. Median stay inthe ICU was 2 days, and total hospital length of stay was 8 days. Thirty-one percent of all patients received neoadjuvant chemo therapy, radiation therapy, or both before MIE. The conversion rate to open was 4.5%. 98% of pts had an R0 resection and the median number of lymph nodes dissected was 21. Stage-for-stage, the survival curves were comparable with those of open esophagectomy In 2000, Nguyen et al.15 compared the minimally invasive approach with open transthoracic and transhiatal esophagectomy The minimally invasive approach documented shorter operative times, less blood loss, and shorter stays in the ICU with no increase in morbidity compared with the open approach 5/5/2021 100 By Abdulmenan Abduljelil

101. references THANKS 5/5/2021 101 By Abdulmenan Abduljelil

102. THANK YOU 5/5/2021 102 By Abdulmenan Abduljelil