Aliu Sanni MD SUNY Downstate Medical Center August 16, 2012

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Annabella McDowell
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1 Aliu Sanni MD SUNY Downstate Medical Center August 16, 2012

2 Case Presentation 60yr old AAF with PMH of CAD s/p PCI 1983, CVA, GERD, HTN presented with retrosternal chest pain on 06/12 Associated dysphagia to solids and liquids, weight loss of 40lbs over last 6months PSHx- Hysterectomy, Bilateral Knee replacements Social Hx- 1ppd X 45years, occasional ETOH & cocaine use Medications- Plavix, Aspirin, Cardizem, lopressor, Imdur, Crestor.

3 Case Presentation Afebrile, BP 130/76, PR 74 General- Cachexia, not pale, anicteric Abd- soft, NT/ND Chest- CTA bilat CVS-S1S2 no murmur Labs CBC 7/10/32/323 BMP- 143/4/107/25/51/1.69/114 Coagulation- 11.6/30/1

4 CT Scan Chest

5 Barium swallow

6 PET Scan

7 Case Presentation Ct Scan Chest- 3 cm soft tissue mass in mid-esophagus. Barium swallow- infiltrative circumferential narrowing of the esophagus suggestive of esophageal CA. PET Scan- Circumferential thickening of the mid esophagus with neoplastic range uptake EUS/ biopsy- Squamous cell CA

8 Case Presentation Pre-operative testing revealed 80% stenosis LAD Bare-metal stent inserted on 7/16/12. Elective surgery planned Re-admitted twice with worsening intolerance to liquids and solids and acute renal insufficiency on 7/25.

9 Case Presentation Tumor board multidisciplinary meeting 1. Surgery with adjuvant Chemoradiation 2. Neoadjuvant chemoradiation with Surgery - Similar outcomes with either options Plan was for Transhiatal Esophagectomy

10 Operative technique Abdominal phase Midline supraumbilical incision Identification and protection of right gastro-epiploic artery Gastric mobilization Kocher maneuver Pyloromyotomy Distal esophageal mobilization Feeding jejunostomy

11 Cervical phase

12 Mediastinal dissection

13 Resection and anastomosis

14 Hospital course POD#1- Extubated POD#3- Chest tube removal POD#7- Barium swallow: small contained leak Adjuvant Chemo-radiation planned

15 Pathology Poorly differentiated squamous cell carcinoma Proximal and distal margins are negative for carcinoma Lymphovascular and perineural invasion 3/7 lymph nodes positive pt3n2mx

History of esophageal resection Czerny 1877-1 st esophageal resection for cervical tumor Torek 1911- resection of thoracic esophagus Dent 1913-1 st Transhiatal

17 History of esophageal resection Czerny st esophageal resection for cervical tumor Torek resection of thoracic esophagus Dent st Transhiatal esophagectomy in cadavers Turner transhiatal esophagectomy for carcinoma Oshawa Thoracic resection with anastomosis Ivor Lewis Ivor Lewis esophagectomy

18 Epidemiology Incidence in the United States is 20 per 100,000 Worldwide incidence : 160 per 100,000 2 major histological types Squamous cell carcinoma 70% found in upper & middle third Most common worldwide Adenocarcinoma Distal third Most common in western world

20 Clinical presentation Asymptomatic Dysphagia (74%) Retrosternal chest pain Weight loss (57%) Hoarseness Aspiration pneumonia

21 Diagnosis Esophagogram Upper endoscopy CT scan chest/abdomen/pelvis Endoscopic US and biopsy PET scan - Resectability

22 Pre-operative Assessment Evaluate physiologic status Cardiac and pulmonary status PFTs Non invasive cardiac evaluation Nutritional status

30 Transhiatal Esophagectomy Better surgical option for patients with poor pulmonary function Contraindications Severe CAD or valvular disease Bulky tumors of mid-esophagus difficult to dissect

31 Transhiatal Esophagectomy

32 Ivor Lewis Esophagectomy Laparotomy Right thoracotomy Anastomosis made in the chest Contraindications Tumors in upper third esophagus Long segment Barrett s with extension into cervical esophagus

33 IVOR LEWIS ESOPHAGECTOMY

34 Modified McKeown/Triincisional technique Combination of Ivor Lewis and transhiatal approaches Laparotomy Right thoracotomy Cervical anastomosis Useful for tumors at any level in the esophagus

35 En Bloc Resection Extensive lymphadenectomy Tri-incisional Ligation of azygos, hemi-azygos, intercostal veins Removal of mediastinal lymph nodes Excision rim of diaphragm Removal of pericardial, left gastric, portal, common hepatic, celiac, splenic lymph nodes Cervical esophago-gastric anastomosis

38 Follow up EGD every 3months for 1 st year and then annually History and Physical Examination every 3months for the 1 st 2years and then annually CT Chest /Abdomen every 6months for 1 st 2years and then annually till 5yrs

46 Conclusion Esophageal cancer remains a challenging disease with poor outcomes regardless of the stage. Surgery remains pivotal in its management. There is no single best practice. Multimodal therapy remains the optimal treatment.

47 Questions When mobilizing the stomach for esophagectomy, which vessel is preserved? A. Left gastric artery B. Right gastric artery C. Right gastro-epiploic artery D. Left gastro-epiploic artery E. Short gastric arteries

48 Questions The T and N status of esophageal carcinoma is most accurately assessed by : A. Upper GI series B. CT Chest and Abdomen C. Endoscopic Ultrasound D. PET scan E. MRI scan

49 Questions Substantial mortality from anastomotic leakage A. Transthoracic (Ivor-Lewis) Esophagectomy B. Transhiatal Esophagectomy C. Both D. Neither

Management of Esophageal Cancer: Evidence Based Review of Current Guidelines. Madhuri Rao, MD PGY-5 SUNY Downstate Medical Center

Management of Esophageal Cancer: Evidence Based Review of Current Guidelines Madhuri Rao, MD PGY-5 SUNY Downstate Medical Center Case Presentation 68 y/o male PMH: NIDDM, HTN, hyperlipidemia, CAD s/p stents,