25. 1 Acute pancreatitis
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Recurrent Intestinal Obstruction
Some patients develop one or more subsequent occurrences of small bowel obstruction. This seems to be a particular problem for patients with extensive, dense intraperitoneal adhesions. Some recurrent obstructions require reoperation, and most surgeons simply free the intestine as described previously. Plication of the small bowel or its mesentery to reintroduce the small bowel into the peritoneal cavity in an orderly manner without kinks has been suggested for these difficult cases. Another method employed to minimize recurrent obstruction of the small bowel is the intraoperative passage of a long intestinal tube through the length of the small intestine, leaving it in place for approximately 2 weeks to maintain an adequate intestinal lumen while healing occurs. Available data suggest that the intraluminal tube stent can be employed with a lower operative mortality rate and a lower rate of reoperation.
TREATMENT OF PARALYTIC ILEUS
Paralytic ileus is treated by nasogastric suction and administration of intravenous fluids. Correction of electrolyte imbalance, especially hypokalemia, is particularly important in managing this disorder. In some cases of paralytic ileus, particularly with extreme distention, a long tube should be passed into the intestine, because this method of suction provides superior intestinal decompression.
Most often, ileus develops after abdominal operation and is transient, lasting 2 to 3 days. When ileus persists or occurs without obvious etiology, one should endeavor to rule out mechanical obstruction or intra-abdominal sepsis; a laparotomy may be necessary to exclude these factors confidently.
Some patients with paralytic ileus develop massive distention of the colon and particularly the cecum. Distention secondary to ileus can threaten bowel viability. Patients with this syndrome are frequently elderly or have multisystem disease. Colonoscopy is a safe and effective way to decompress massive nonobstructive cecal dilatation in high-risk patients.
OESOPHAGUS.
VIGOROUS ACHALASIA
Vigorous achalasia has features of both classic achalasia and diffuse oesophageal spasm. Chest pain Is a more prominent feature than in achalasia, in addition there is dysphagia and regurgitatlon.
There is segmental spasm of the lower oesophagus with dilatation of the proximal half and retention of food material.
Calcium channel blocker (nifedipine) may give symptomatic relief. The surgical treatment consists of an extended myotomy from the level of the aortic arch to the gastrooesophageal junction through a left thoracotomy. The results are satisfactory.
PHARYNGEAL DIVERTICULUM
Pharyngeal divertlculum, is a pulslon divertlculum, (i.e. a result of pressure from within) which protrudes between the oblique fibres of the Inferior constrictor and the transverse fibres of the cricopharyngcus (Fig. 38.5). Contributory factors Include a high pressure developing in the proximal oesophagus, as a result of oesophageal spasm. The divertlculum enlarges first lying posterior and then to the left of the oesophagus. The sac consists of mucosa and submucosa only. Complications may arise from aspiration of pouch contents which cause chest infection and lung abscess. Occasionally, a carcinoma occurs in the pouch.
Clinical Features
Usually, pharyngeal diverticulum occurs in an elderly male. The pouch may compress the oesophagus and produce dysphagia. There may be a visible swelling in the neck. Gurgling noise after eating and bad breath are the common symptoms.
Diagnosis
X-ray shows a smooth rounded outpouching arising posteriorly in the midline of the neck. The dysphagia produced by the diverticulum should be distinguished from that produced by a malignant lesion.
Treatment
Treatment consists of excision of the diverticulum and myotomy of the cricopharyngeal muscle (Fig. 38.6).
OESOPHAGEAL PERFORATIONS
The causes of perforation are: (i) inexpert instrumentation, (ii) penetrating injuries, or (ill) spontaneous perforation.
Inexpert Instrumentation Instrument may damage the posterior watt }ust' above the cricopharyngeal sphincter, the wall being crushed between the shaft of the Instrument and rigid spine. Perforation may also occur near the cardia. Perforation just above an oesophageal stricture can occur from bouginage or endoscopy. Removal of a piece of growth, for biopsy may at times result in perforation.
Clinical Features
During oesophagoscopy, the endoscopist may often recognise the mischief done. Severe agonising pain In the chest and the back is usually complained by the patient. Just after recovery from anaesthesia. The pain is aggravated during swallowing. There is subcutaneous emphysema at the root of the neck and patient runs high fever. In untreated cases, cellulltis of the neck region occurs. In a thoracic perforation, there are signs of hydropneumothorax.
Investigation*
X-ray shows displacement of the trachea anteriorly by air or fluid. Later, widening of the superior mediastinum may be seen. With thoracic perforation there is pleural effusion.
Management is discussed In detail later.
Penetrating Injury See Chapter 35 on Chest Injuries.
Spontaneous Perforation (Boerhave's Syndrome)
Spontaneous perforation occurs mainly in men after alcoholic excess or in association with severe vomiting. The rupture usually involves all layers of the oesophageal wall. The tear results from excessive intraluminal pressure generated by violent retching and vomiting, and is mostly in the distal part of the oesophagus. The tear is always longitudinal and varies from 1 to 5 cm in length.
Following perforation, air and gastric contents escape Into the mediastinum leading to mediastinitis. Mediastinal pleura later gives way releasing air, gastric contents and the inflammatory exudate into the pleural cavity.
Clinical Features
It produces severe pain with mild haematemesis (in contrast with the Mallory-WeIss syndrome In which there is mild pain, greater haematemesis and only rarely a full thickness perforation). The triad of vomiting, low chest pain and subcutaneous emphysema are characteristic of spontaneous rupture of oesophagus. Dyspnoea, cyanosis and shock usually accompany. Clinical examination of chest reveals hydropneumothorax.
Investigations
X-ray chest shows mediastinal emphysema and hydropneumothorax. In doubtful cases, gastro-grafin swallow may reveal the site of leakage.
Management of Oesophageal Perforations
Most of the surgeons agree that perforations of the oesophagus are best treated by Immediate surgical exploration, repair and drainage, but this may not always be possible.
Antibiotic therapy with a cephalosporin and metronidazole is started as soon as the diagnosis Iq made in addition to resuscitation with volumej replacement. On radiological confirmation of pleural effusion, an underwater seal chest drain is inserted.
The vast majority, as already mentioned, would prefer surgery which should be carried out as soon as possible after resuscitation. The mortality rises several fold if the perforation is treated surgically beyond 24 hours Of onset.
The result of treatment for perforation of the cervical oesophagus has been excellent with early exploration, but even with contamination and delayed treatment, the results of surgery have been generally satisfactory.
For intrathoracic oesophageal perforation, the repair within 24 hours has mortality rate around 10%. If the treatment is delayed beyond 24 hours, the mortality rises to 50 per cent due to associated medlastinitis and toxaemia.
In late cases and with small perforations (minor guide wire induced perforations), success may be obtained by nonoperative management (cessation of oral food and drink, antibiotic therapy, nasogastric aspiration, parenteral nutrition and underwater seal pleural drainage).
The high mortality associated with late diagnosis in intrathoracic perforations has led to the following options in treatment.
Nonoperative Management
These patients are very ill, in very low condition. and at times the only course to adopt is the non-operative management of parenteral alimentation, antibiotics and intercostal tube drainage.
Operative Management
This may consist of taking following steps.
1. A temporary cervical oesophagotomy and «x feeding jejunostomy to isolate the perforation.
2. Alternatively, the site of perforation is dissected and the proximal end of oesophagus is brought to the neck. The distal end is closed and a feeding jejunostomy is established. At a second stage, a colonic interposition is performed to bridge the site of previous dissection.
FOREIGN BODIES IN THE OESOPHAGUS
Most cases occur in children and mentally disturbed patients. Oesophagus may become obstructed by impaction of meat or a large fruit seed especially in an edentulous patient. Foreign bodies lodge at one of the three levels: (i) at the pharyngooesophageal junction in the neck, (U) adjacent to the aortic arch in the chest, and (ill) In the distal oesophagus, just above the cardia. Pain in the midline of the chest or neck is a prominent symptom.
Diagnosis
A plain X-ray or a water soluble contrast medium (Gastrografin) swallow may show the foreign body. Oesophagoscopy is diagnostic.
Treatment
Many foreign, bodies will pass on their own. Most, however, should be removed by endoscopy. When the foreign body has been visualised, it may be manipulated into a favourable position, so that it may be grasped with suitable forceps introduced through the oesophagoscope. The oesophagoscope together with the forceps still grasping the foreign body is then gently withdrawn. At times, the sharp , foreign body or impacted partial denture may have j to be removed by oesophagotomy in the cervical or | the thoracic oesophagus.
CORROSIVE STRICTURES OF THE OESOPHAGUS
A variety of chemicals may produce corrosive bum of the oesophagus. Mineral acids (e.g. hydrochloric acid, nitric acid), caustic soda and organic solvents are the principal agents.
Pathology.
Following ingestion of corrosives, there occurs oedema, . congestion and inflammation of the mucosa and submucosa. The extent of damage to the oesophagus depends upon the concentration and the length of time the irritant remains in contact with the mucosa. If the Inflammation is severe, the vessels undergo thrombosis and sloughing of mucosa and submucosa results. Acute phase lasts for about 2 to 3 weeks. Healing takes place by stricture formation. Stricture of the pylorus may also take place in some. Corrosive stricture of the oesophagus usually involves a long segment of its lower part. The strictures are sometimes multiple. Denser strictures are located at the areas of normal narrowing in the oesophagus.
Clinical Features
During Acute Phase
Most common finding is inflammatory oedema of the ., lips, mouth, tongue and oropharynx and there is burning pain in the lips, tongue and mouth. Patient complains of severe substernal pain, dysphagia and shock and there is dribbling of large quantities of saliva.
During Chronic Phase
The difficulty in swallowing progresses rapidly until a small trickle of fluids passes down the oesophagus. There is loss of weight, and emaciation. There are old scars on the lips and cheek.
Management
Immediate Treatment
1. Neutralising agents are given by mouth, soon after the accident. 2 per cent acetic acid in case of an alkali bum and dilute sodium bicarbonate in an acid bum.
2. Oral fluids are withheld for about one week and IV fluids administered. ;
3. Steroids are given for stx weeks (to minimise flbrosis), together with antibiotics.
4. Oesophagoscopy is sometimes advocated after a week when the acute inflammation has subsided. This is to determine the extent of damage. An utmost care is observed during the procedure. , i Early bouglnage with the help of mprcury bougies is advocated by some. I
.
Treatment In an Established Case
1. Oesophagogram to determine the site and number of strictures and the extent of Involvement.
2. Oesophagoscopy to confirm the X-ray findings.
3. Periodic oesophagoscopic dilatation with oeso-phageal bougies at 2 to 3 weeks interval.
4. When the stricture is very dense and dilatation is difficult and dangerous and the patient's general condition Is low, a feeding jejunostomy is established.
5. Oesophageal reconstructive surgery is indicated when: (i) repeated dilatation cannot maintain a satisfactory lumen, (ii) stricture cannot be dilated, and (iii) repeated dilatation is not acceptable to the patient.
The reconstructive procedures are the following.
- For small localised strictures, excision of the strictured segment and replacement with a segment of jejunum or colon.
b.For long segment strictures, total bypass of the strictured oesophagus by a segment of the right or left colon or replacement of oesophagus by stomach.
GASTRO-OESOPHAGEAL REFLUX
The oesophagogastric junctional area of the cardia is so designed that it normally does not allow stomach contents to regurgitate into oesophagus. How this arrangement works is still not fully understood. There is not much muscle thickening at the cardia, which would characterise, an anatomical sphincter, and the sphincteric action is perhaps mostly based on its physiological role. In general term, the cardia pertains to an area which includes the lower oesophagus, the oesophagogastric junction and the uppermost part of the stomach. The cardia is assisted by 'the following towards its better performance.
1. The Intra-abdomlnal segment of oesophagus An adequate length of the intraabdominal oesophagus (Fig. 38.8) helps the physiological sphincteric role of the lower end, and it plays an important part in the prevention of reflux. A positive intra-abdomlnal pressure flattens this segment against the supporting crura which prevents suction of the gastric contents into the chest.
2. The phrenooesophageal ligament It Is the condensed mature collagenous tissue which is a continuation of the transversalis fascia of the abdominal wall, and it Inserts on the circumference of the lower thoracic oesophagus, 2 to 3 cm above the true junction. The phrenooesophageal ligament has an Important supporting role. Due to the laxity of this ligament in old age, the true junction may tend to slide up and the incidence of hiatus hernia thus increases, and In patch graft of stomach fundus allows maximal correction of the stricture. The stomach fundus acts as an anti reflux barrier. The short oesophagus may function fairly well within the chest (Fig. 38.15b).
Angelchik Prosthesis
Anglechik prosthesis is a C-shaped silicone gel filled device (Fig. 38.15) for the surgical treatment of gastrooesophageal reflux. Its chief advantage lies in its relative ease and rapidity of insertion. It provides good and lasting relief from symptomatic reflux. It is not easily available in India and moreover is costly. The available techniques of fundopllcatlon have proved to be safe and effective in most hands and its use may not be necessary.
BENIGN TUMOURS OF THE OESOPHAGUS
Leiomyoma
A leiomyoma is the most common benign tumour of the oesophagus which usually occurs in the lower oesophagus. It either arises in the muscularis mucosa, in which case it forms a pedunculated intraluminal mass, or in the muscularis propria, in which case it grows In the oesophageal wall and may present as a mediastinal mass. They, rarely cause symptoms, because the oesophageal lumen is displaced around the tumour and, therefore, obstruction does not occur till late. Barium swallow shows a smoothly rounded, often spherical mass, Intraluminal growths can be recognised at oesophagoscopy and often with intact mucosa. Biopsy is risky because there is risk of haemorrhage and perforation. As the tumours are well encapsulated, they can be removed by enucleation without oesophageal resection. The cut surface of the tumour is characteristically white and whorled in appearance. However, a careful follow-up is necessary.
CARCINOMA OF THE OESOPHAGUS
Epidemiology and Aetiology
One of the most intriguing feature is its geographical variability. In most parts of the world. the incidence per 100,000 population is 2.5 to 5.0 for males and 1.5 to 2.5 for females, but the incidence may exceed 100 in certain areas of high risk in China and Iran. These patients do not drink alcohol nor smoke tobacco, but use of opium is widespread. How much of opium pipe residue is responsible for this is not clear. They suffer from nutritional deficiencies and drink hot beverages. The recurrent thermal Injury has been blamed. Poor nutrition is common in high risk areas where vitamin deficiency of A and C has been implicated. Fresh vegetables are scarce in these high risk areas, leading to riboflavin deficiency which has been shown to cause oesophageal atrophy in experimental animals, a condition which may be premalignant. N-nitoso compounds (especially in pickled vegetables) may be responsible in high risk areas. Fungal contamination of food is of aetio-logical importance in some regions of the world.
There are usually more cases among males than females (3:2), however there is female predominance in the upper third of oesophagus. In the USA, it Is commoner amongst blacks than whites. For most of Europe low rates of oesophageal cancer are comparable to those of North American whites.
It has been estimated that more than half of all oesophageal cancer cases in the world occur among ethnic Chinese. In mainland China, it is the second most common cancer. In the United States also, ethnic Chinese experince a rate which exceeds that of local Caucasians.
In India, there is no well established population based data for carcinoma oesophagus. Data from various sources, however. Indicate that oesophageal cancer is an important problem in India. The role of tobacco chewing In the aetiology of pharyngeal cancer has been demonstrated by many studies and oesophagus being in direct contiguity, the association seems logical. Its frequency is higher in Orissa coast, Kamataka and the North East. Is it because of the fermented pickled food being consumed in these areas? This type of food contains N-nitroso compounds.
'Tyiosis (thickening of the skin of palms and soles), a rare inherited disease is associated with a very high risk of cancer. Achalasia and chronic stricture have been reported to develop carcinoma after a long Interval. Head and neck cancer patients may develop carcinoma of oesophagus, as the same aetiological factors play their part down below.
Barrett's oesophagus (columnar cell epithelium in the lower oesophagus/as a regeneration response to damage by reflux oesophagitis) is widely believed to be premalignant.
Screening Methods in High Risk Areas
Dysphagia Is a late symptoms and it 16 not possible to detect early cases while screening asymptomatic people in high incidence areas of the world. These areas include parts of Iran, China and Africa where the risk is up to 20 times greater. The screening methods are based on cytological evaluation of cells from the oesophagus by various methods. In Iran, a standard endoscopic brush Is passed via a nasogastric tube. In China, they use an abraise balloon; a string with balloon covered with fine mesh at one end is swallowed. The balloon is inflated by air and then pulled up the oesophagus. Cells from th'" mesh are collected for cytological examination.
In USA and other low risk countries, the incidence of carcinoma oesophagus is too low to justify mass screening.
Pathology
Carcinoma of the oesophagus may be squamous or an adenocarcinoma. Malignant tumours arising proximal to the cardia, i.e., the true oesophageal tumours, are almost all squamous cell carcinomas. Those of the lower oesophagus in direct continuity with the cardia are usually adenocarcinomas. Primary adenocarcinoma of the body of the oesophagus is rare (about 3%), but it may arise anywhere along its length from small submucosal glands, or in the distal portion from the abnormal epithelium of Barrett's oesophagus.
In past, it was a well recognised fact that the majority of histological types were squamous cell carcinoma, but the recent studies indicate that the incidence of adenocarcinoma now makes up about 30 to 40 per cent of the annually diagnosed oesophageal cancer. The majority of adenocarcinomas are found in the distal third. These may be either primary carcinoma arisng in areas of Barrett's oesophagus or oesophageal extension of stomach carcinoma.
The oesophagus is traditionally divided into upper, middle and lower thirds. 20 per cent of squamous cancers occur in the upper third, 50 per cent in the middle third and 30 per cent in the lower third. If adenocarcinoma of cardia is also included in the lower third, it becomes the most common site of oesophageal cancer.
Three types of more advanced tumours are recognised: (1) fungating growth (60%) extending irregularly Into the oesophageal lumen; (U) ulceraltive (20%); (ill) annular (15%) with extensive infiltration of the oesophageal wall.
Spread
Lymphatic spread occurs early due to the rich submucosal lymphatic network. The spread occurs first within the oesophageal wall often producing satellite lesions, which progresses to lymph nodes In the neck, mediastinum and abdomen. Local mediastinal structures especially the bronchi and trachea are often invaded giving rise to fistula. An autopsy study showed that abdominal lymph nodes were involved in 40 per cent of the upper one third tumours, and that cervical nodes were involved in 60 per cent of the lower third tumours. In view of the extensive submucosal spread, at least 10 cm clearance at surgery is advised. The lung and liver are the most common sites of distent blood-borne spread.
Staging
The TNM System of Clinical Staging is given below.
Tumours (T)
Prelnvasive carcinoma (carcinoma (n situ).
to No evidence of primary tumour.
T. Tumour involving 5 cm or less of. the oesophageal length, producing no obstruction. Does not involve the entire circumference and shows no evidence of extraoesophageal spread.
T Tumour involving more than 5 cm of the oesophageal length and with no evidence of extraoesophageal spread or tumour of any ' size producing obstruction and/or , Involvement of the entire circumference but with no extraoesophageal spread.
T3 Tumour with evidence of extraoesophageal spread, such as recurrent laryngeal, phrenic or sympathetic nerve Involvement, fistula formation. Involvement of trachea or bronchial tree, vena cava or azygos vein obstruction or malignant effusion.
Nodes (N)
Cervical Oesophagus
No. No evidence of regional lymph node
Involvement. N. Evidence of involvement of mobile unilateral
regional nodes. N3 Evidence of involvement of mobile bilateral
regional nodes. N3 Evidence of fixed regional nodes.
Thpracic Oesophagus
no No evidence of regional node involvement on
exploration, medlastinoscopy, or CT scan. n| Involved regional nodes.
Distant Metastases (M)
mq No evidence. M< ' Presence of distant metastases. Specify site.
Clinical Featuros
The disease is commoner in men. Persons between 40 and 60 years are the usual sufferers. (This age Incidence is considerably lower than that reported in Western Series.) Nearly, all patients who present for diagnosis and treatment, are the late cases.
Symptoms
1. Dysphagia Oesophagus has a remarkable capacity to distend and dysphagia is a late sign.
Dysphagia does not occur until almost the entire circumference is involved. This is, however, the leading and often the only symptom. The dysphagia Is progressive—first with solids and then with liquids as well.
2. Loss of weight and weakness are the direct result of patient's Inability to take sufficient quantity of food.
3. There may be pain or retrosternal discomfort In the later course of disease.
4. Patient may complain of regurgitatlon of food, mixed with froth and saliva and often streaked with blood.
5. Coughing related to swallowing indicates either a high lesion or the presence of tracheo-oesophageal fistula.
6. Hoarseness of voice denotes spread to the recurrent laryngeal nerve.
7. Persistent hiccup is due to phrenic nerve Involvement.
Signs
1. Anaemia, cachexia, dehydration
2. Supraclavlcular lymph node enlargement
3. Palpable lump in the epigastric region (lymph nodes in the coeliac region)
4. Hard large liver, ascites, pelvic mass due to peritoneal secondaries.
Investigations
A patient with dysphagia is first tested with barium. Barium swallow may show a persistent irregular filling defect. In the lower part, the irregular narrowing is typically described as a 'rat tall' deformity (Fig. 38.16). The endoscopic biopsy is now done.
If the barium study is- normal and the symptoms continue, endoscopy is required especially tf patient consumes excess tobacco and alcohol or Barrett's oesophagus due to reflux is suspected. Endoscopic biopsy is positive in most cases. Biopsy can be directed by spraying the mucosa with Lugol's iodine through the endoscope. the glycogen containing squamous epithelium gets its dark stain thus directing biopsy to the unstained area.
Patient should be evaluated for the spread of the disease. A careful palpation of cervical and supraclavlcular lymph nodes is Important. In- a primary tumour of the cervical oesophagus, Involved lymph nodes In the neck region are the regional metastases. If the primary tumour is In thoracic oesophagus, then the neck nodes should be considered as the distant metastases.
X-ray chest and bronchoscopy are done to evaluate involvement of lungs and air passages. CT is useful in determining both local and distant metastases. It is the study of choice for pre-operative staging and for spread to liver and lungs.
Endoscopic ultrasonography is a new imaging technique that may aid In the evaluation of tumours and dysphagia In oesophagus. The transducer is applied directly to target organ. It gives better resolution and exquisite detail. It is more accurate than CT in assessing the depth of tumour invasion and lymph node Involvement.
Treatment
The treatment depends on the stage of the disease and the condition of the patient. The nutritional state may need to be improved by a period of enteral or parenteral nutrition before surgery is undertaken.
The treatment options available are the following.
1. Surgical resection
2. Radiotherapy
3. Intubation
4. Laser treatment
5. Chemotherapy.
Surgical Resection
Though the Chinese have reported 90 per cent 5-year survival after total oesophagectomy for an early lesion, nearly all patients who present for diagnosis and treatment are symptomatic with dysphagia and no longer represent an early case. Most have lymph node involvement and Invasion beyound oesophagus. A large number of patients are unsuitable for surgical treatment. In those undergoing resection, the long-term survival Is low and surgical mortality and morbidity remains high.
A proper case selection and preoperative assessment before embarking on surgery Is essential, hi patients where preoperative evaluation (also confirmed intraoperatively) suggests that the primary tumour is early, total oesophagectomy is the curative treatment. When preoperative staging shows extension of the disease (majority of cases fall in this category), there is nodal disease and full wall penetration, a pallatlve resection only .can be undertaken.
Because the rich submucosal lymphatic plexus favours longitudinal spread of tumour within the oesophagus, total oesophagectomy is the preferred approach. Segmental resection is not advised as it frequently results In microscopic foci of residual tumour at the surgical margin and a high incidence of local recurrence. The average operative mortality for carcinoma oesophagus is about 26 per cent, but it provides a more reliable and prolonged palliation of dysphagia.
Cervical oesophagus Despite extensive reconstructive efforts, the radical surgery for cervical oesophagus results in major functional disability. The surgery (pharyngolaryngectomy with gastric or colonic interposition) is a major undertaking associated with a high complication rate and mortality and 5-year cure rates have been 10 to 20 per cent. Primary radiation therapy series have produced similar results without mortality of surgery and the loss of voice and swallowing mechanism that laryngopharyngo-oesophagectomy entails.
Carcinoma middle third Carcinoma of the middle third may not be diagnosed till late. It may become adherent to the aorta, vena azygos or the left main bronchus. Curative resection may not be possible.
For curative resection, total oesophagectomy is performed. The segmental oesophagectomy is no longer preferred.
Carcinoma (ower third Total oesophagectomy is aimed at to achieve satisfactory cure.
In all procedures, a laparotomy Is done first to mobilise the gastric conduit. In the total thoracic oesophagectomy (segmental oesophagectomy Is no longer preferred), the gastric tube is brought up either substemally or through the posterior mediastinum, and the anastomosis is completed in the neck.
The intrathoracic oesophagus is dissected either through a right thoracotomy or by the transhiatal method. The transhiatal oesophagectomy consists of blunt dissection of the intrathoracic oesophagus performed through oesophageal hiatus and thp thoracic Inlet without an open thoracotomy. The oesophagus is dissected bluntly from both cervical and abdominal incisions. The gastric tube is placed into the posterior mediastinum and anastomosis in the neck is performed. The transhiatal oesophagectomy Is most useful In upper third or distal third tumours For middle third tumours, there l8 a possibility that in some there is inadequate resection and complete lymph node removal may not be possible. With this blunt technique, there may be risk of tracheobronchial or vascular Injury.
The reconstruction following resection may be done by stomach, colon or jejunum. The stomach is easily mobilised and has an excellent blood supply. An extensive network of intramural vessels supplies the fundus even when the left gastric and left gastroeplploic vessels are divided during mobilisation. Stomach is fairly adequate in length to reach the neck in all individuals. If patient has had a previous partial or total gastrectomy or if stomach is extensively involved with tumour, it may become necessary to use another type of replacement. The colon is most commonly used. Alternatively, either the right or the left colon can be used. a barium enema or colonoscopy should be done to rule out a synchronous colon cancer or Inflammatory changes in the colon. The colonic replacement has a higher mortality rate than gastric replacement. There is need for two additional anastomoses (i) coloje-junostomy, and (ii) colocolostomy. However, the long-term function of the replaced colon has been excellent. Jejunal loop as replacement has restricted mobility with unpredictable blood supply and, therefore, it has restricted its popularity. More recently, free jejunal interposition has been used successfully. Vascular access is usually obtained from external carotid artery and external jugular vein.
Palliative bypass A tumour may be deemed resectable on preoperative staging but found Inoperable at thoracotomy, a reversed gastric tube may be fashioned (Fig. 38.17), or a colonic, bypass (Fig. 38.18) arranged and brought up to the neck for anastomosis to the cervical oesophagus either via the subcutaneous or retro-stemal route.
The bypass procedures are less popular than intubation procedures because they carry a high mortality which averages 30 per cent and are major procedures not Justified in patients with advanced disease or poor general condition with limited survival.
Radiotherapy
The use of preoperative Irradiation has been advocated to decrease the tumour bulk and Increasing chances of resection. It also treats the perioesophageal spread and treats areas not easily approached by surgery. However, there is no Improvement in survival as compared to control, and preoperative irradiation cannot be recommended as a routine procedure.
The use of postoperative irradiation for possible residual tumour during resection has been advocated.
For those patients where surgery is inadvisable due to extensive disease. Irradiation may be the primary treatment. It may provide substantial local response and good local palliation, although the frequency and duration of relief varies. There are certain relative contraindications to palliative radiotherapy: (i) patient with evidence of metastatic disease, and (11) patient with tracheo-oesophageal fistula.
Endoscopic intr-aluminal brachytherapy may provide an Increased biologically effective dose to the primary tumour. This technique may provide palliation of dysphagia in some patients who develop either local recurrence of the oesophageal carcinoma, or fail to achieve satisfactory palliation with external beam therapy.
Intubation
Though surgical palliation for dysphagia is good and lasts longer, but it has a high mortality. Palliative surgery should only be used by the most experienced, and when they have such little time to live, the need to develop better methods than surgery is worth considering. The alternative of nonsurgical palliation in form of dilatation and intubation has, therefore, received considerable attention.
Peroral dilatation of a malignant stricture can be done with proper care. Eder-Puesto guide wire is passed down the stomach under fluorosocopic (or under direct) vision, and gradual dilatation is done.
In cases where peroral dilatation facility is not available, prosthesis can be placed through the malignant stricture to create an effective channel for food. It is good for middle and lower third lesions. Different types of tubes for palliation of an oesophageal carcinoma are used. The Celestin tube is commonly used. It may be introduced by passing the tall of the tube through the stricture into the stomach at oesophagoscopy, and then making a small opening in the stomach at laparotomy and pulling the tube down until Its upper end sits well above the tube. Mousseau-Barbin tube was also devised which had a funnel-shaped upper end, an intermediate tube and a long flexible guide which can be passed through the stricture. The procedure of insertion itself has considerable mortality and various complications have been reported, therefore, this is no longer recommended. The Souttar tube can also be inserted through an oesophagoscope and does not need gastrotomy.
However, there is a tendency for these to become dislodged or blocked with food. Further concomitant radiotherapy increaes the complications, (e.g. bleeding, perforation) of tubes. Therefore, intubation should only be reserved for patients with extensive disease and a life expectancy of few months.
loser Treatment
In some patients with unresectable tumours. dysphagia can be relieved by endoscopic laser therapy.