What is the esophagus?
Esophagus is the medical term for the food pipe which connects the pharynx area to the stomach. Based on the distance from the incisor tooth it is classified as upper , middle and lower third . The portion of the esophagus which joins the stomach is called the gastroesophageal junction and is a regular site for cancer.
What causes esophageal cancers?
Well known risk factors are smoking and alcohol consumption. There are other presumptive but not well proven risk factors like eating spicy food and drinking excess coffee. These presumptive factors have been proposed for the higher incidence of esophageal cancers in south India especially in parts of Karnataka and Tamil Nadu
Reflux disease due to various causes are known to cause changes at the GE junction and lower esophagus leading to development of cancer
"You can hear Dr Anil Kamath speaking on various aspects of Esophageal Cancer:"
What are the symptoms of esophageal cancer?
Let me describe a typical patient with esophageal cancer. Please be mindful that the typical symptoms may not be present in each and every patient.
Mr Sampat (presumptive name) is a 60-year-old gentleman, He is a regular smoker and has been smoking 5 to 6 cigarettes a day for the last 25 years. He occasionally consumes alcohol also. Off lately, he had been feeling food getting stuck in his chest. This symptom has been there for the last month and half. Initially this sensation was there for solid food like chapattis. He had to drink water after consuming food to digest it but lately he has been having this sensation for liquids too.
The symptom of difficulty in swallowing known as dysphagia is the hallmark of esophageal cancer.
The dysphagia is usually progressive which means that it keeps increasing in severity.
A few patients may have cough after taking food which may be due to food contents going into the respiratory tract a symptom known as aspiration.
Pain is not a regular feature of esophageal cancer except in later stages where it has infiltrated the surrounding nerves.
What are the tests done for esophageal cancer?
The most important test is an upper GI endoscopy in which a lighted tube with a camera is passed through the mouth. This helps to visualize any growth or ulcer in the esophagus and even take biopsy if required
The next test is usually an imaging which can be either CT scan or a PET scan. This helps to know the spread of the disease
How is esophageal cancer treated?
Treatment will depend on
Surgery, radiation and chemotherapy are the three main options used for esophageal cancer .
It is very rare to get esophageal cancer in stage 1. In most cases it is either stage 2 or 3. The treatment required is multi modality which means that treatment has to be a combination of surgery, chemotherapy and radiation.
Once a patient has been diagnosed to have esophageal cancer the details should be discussed in a tumour board where a surgical , medical and radiation oncologist is present.
Which treatment should be started first?
Assuming the patient is at stage 2 and 3, mid and lower esophageal cancers the initial treatment would be chemotherapy and radiation. This treatment will last for 4-6 weeks Following radiation there is usually a waiting period of around 6 weeks to get maximum response
This is usually followed by surgery and further chemotherapy
This type of treatment has been found to have the best results in various trials
In adenocarcinoma many oncologists may decide to omit radiation and go with only chemotherapy and surgery
What is the surgery done for esophageal cancers?
The type of surgery done will depend on where the cancer is located
The type of surgery done will depend on where the cancer is located Except the lower 3rd , it is difficult to remove only the affected part of the esophagus. In most of the cases the entire esophagus may have to be removed, procedure known as total esophagectomy
As the cancer spreads to the nearby lymph nodes along with the esophagus the lymph nodes too are removed The esophagus is usually replaced by making a tube out of the stomach and pulling it up. It is called gastric pull up.
Cancers of the upper 3rd of the esophagus are not usually considered for surgery because of the proximity to the voice box.
In cancers of the lower 3rd and GE junction , provided suitable , lower esophagus and upper stomach is removed and the joint is made between the remaining esophagus and the remaining stomach.
What are the challenges in esophageal cancer surgery?
These types of surgery are highly complicated and require considerable training and skill. The aorta and the bronchus are close to the esophagus and any injury to these structures can be life threatening.
The chances of lower respiratory infection is quite high in this type of surgery
The joint between the esophagus and stomach can sometimes leak leading to infection and sepsis
What are the recent advancements in esophageal surgery ?
The advent of robotic surgery has been a major advancement for surgical treatment of cancer esophagus. Previously patients used to undergo opening of the chest through a long incision . This not only caused a lot of pain but led to increased lung infections as the patients were not able to cough out secretions well. Through thoracoscopic surgery the same surgery could be done using keyhole incisions. Robotic surgery has been an advancement over thoracoscopic surgery as it gives the surgeon dexterity which hands offer along with small incisions. The respiratory complications and pain is far lesser.
Are there any long term side effects of esophageal cancer surgery?
Since this is a major surgery which leads to disturbance of the normal anatomy long term side effects are possible
As there is loss of part of the stomach most patients tend to loose weight
As the valve at the lower end of the esophagus is disturbed there can be reflux of the bile into the food pipe . Patients usually complain of vomiting sensation and bitter taste in the mouth Sometimes the new joint made between the esophagus and stomach may become narrow and may need endoscopic dilation.