TREATMENTS

  • Minimally Invasive Approach to Surgery
  • Dr. Tank
  • info@dravinashtank.in
  • +91 88660 20505

Esophagus

Achalasia Cardia



Introduction

Esophageal achalasia is an esophageal movement disorder that affects the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES).

The esophagus is the tube like organ that facilitates food from the mouth to the stomach. The lower esophageal sphincter (LES) is a muscular ring that open after food is swallowed and closes the esophagus from the stomach when empties into stomach. In achalasia, your LES fails to open up during swallowing, which it’s supposed to do. This leads to a backup of food within the esophagus.



Risk Factor

In Achalasia, initially nerves of esophagus are damaged due to unknown reason. Later on muscles of the esophagus are also gradually damaged. Most of the time, underlying causes is unknown. But in some cases there may be underlying cancer of esophagus.

Symptoms

The main symptoms of achalasia are difficulty in swallowing (dysphagia), vomiting out (regurgitation) of undigested food and weight loss. Dysphagia tends to become progressively worse over time and to involve both fluids and solids.

Some people may experience coughing when lying in a horizontal position. Food/liquid/saliva is retained in the esophagus and may be inhaled into the lungs (aspiration).

The chest pain experienced and non-cardiac chest pain can often be mistaken for a heart attack.

Diagnosis

There is no blood test to diagnose esophageal achalasia. Specific test like Barium swallow, manometry & endoscopy are done. In barium swallow X-ray is being taken while drinking special liquid. Esophageal manometry records the movement of esophagus with the act of swallowing. Endoscopy shows dilation of esophagus or underlying cancer.

Complications

  •   Aspiration Pneumonitis
  •   Cancer
Treatment

There is no treatment to correct the underlying problems of nerves or muscles. Available treatment is directed towards relief of symptoms. Medical treatment is directed to relax the lower esophageal sphincter & fasten the process in food emptying.


Endoscopic treatment options are

  •   Endoscopic Balloon dilatation
  •   Endoscopic Botulin injection
  •   Endoscopic POEM (PerOralEndoscopicMyotomy)
Surgery
  •   Laparoscopic Heller’s Myotomy
  •   Esophageal Resection: Definite treatment of achalasia is resection. So resection if esophagus is advised after all simple treatment fails to improve symptoms. Common indications are so much dilated (tortuous esophagus/megaesophagus/sigmoid esophagus) & failure of more than one myotomy, or an undilatable reflux stricture. In addition to definitively treating the end-stage achalasia, esophageal resection also eliminates the risk for carcinoma.

Foreign body Ingestion



Introduction

Foreign body ingestion and food bolus impaction occur commonly. The majority of ingested foreign bodies will pass spontaneously without the need for intervention.

Risk Factor

The majority of foreign body ingestions occur in the children ages of 6 months and 6 years. In adults, foreign body ingestion occurs more commonly in those with psychiatric disorders, developmental delay & alcohol intoxication. Edentulous adults are also at greater risk of ingesting foreign bodies, including an obstructing food bolus or their dental prosthesis. Patients presenting with food bolus impaction often have underlying esophageal pathology directly leading to the impaction. Commonly ingested foreign body are short-blunt objects (coins), long objects (more than 6 cm: tooth brush), sharp pointed objects (chicken & fishbones, paperclips, toothpicks, needles, dental bridges), disk batteries, magnets, narcotics packets.

Symptoms

Feeling of choking, refusal to eat, vomiting, drooling, wheezing, blood-stained saliva, or respiratory distress are common symptoms. Some patients, may not have any symptoms or some of them may present with complications of the ingested foreign body.

Diagnosis

X-ray is initial investigation to location the site of foreign body. But few things are not visible by x ray like fishbone.

Complications

If foreign body remains impacted for longer duration, it may lead to blockage of intestine (obstruction) & puncture of the intestine (perforation).

Treatment

Endoscopy is the first line of treatment for removal of foreign body. The timing of the removal depends on the patient age and clinical condition; the size, shape, content, anatomic location of the ingested object, and the time since ingestion. Emergent endoscopy is advised if patients has esophageal obstruction (ie, unable to manage secretions), disk batteries in the esophagus & sharp-pointed objects in the esophagus Urgent endoscopy is advised for esophageal foreign objects that are not sharp-pointed, esophageal food impaction in patients without complete obstruction, sharp-pointed objects in the stomach or duodenum, objects more than 6 cm in length at or above the proximal duodenum & magnets within endoscopic reach.

Nonurgent endoscopy is advised:

  •   Coins in the esophagus may be observed for 12-24 hours before endoscopic removal in an asymptomatic patient,
  •   Objects in the stomach with diameter of more than 2.5 cm Disk,
  •   Batteries and cylindrical batteries that are in the stomach of patients without signs of GI injury may be observed for as long as 48 hours,
  •   Batteries remaining in the stomach longer than 48 hours should be removed.
Surgery

Surgery is advised only if narcotics packet is ingested and get impacted. Surgery help to remove the packet without leakage. Otherwise surgery is the option only if complications like obstruction or perforation of intestine develops.


REFLUX



Introduction

Gastroesophageal reflux disease (GERD) is a chronic digestive disease that occurs when stomach acid or, occasionally, bile flows back (refluxes) into your food pipe (esophagus). The backwash of acid irritates the lining of your esophagus and causes GERD signs and symptoms.

In normal digestion, once we eat, food travels from mouth to stomach through a tube called the esophagus. At the lower end of the esophagus is a small ring of muscle called the lower esophageal sphincter (LES). The LES acts like a one-way valve, allowing food to pass through into the stomach. Normally, the LES closes immediately after swallowing to prevent back-up of stomach juices, which have a high acid content, into the esophagus.

GERD occurs when the LES does not function properly allowing acid to flow back and burn the lower esophagus. This irritates and inflames the esophagus, causing heartburn and eventually may damage the esophagus.



Know about GERD (Gastro-Esophageal-Reflux-Disease)

Gastro-Esophageal-Reflux-Disease

Symptoms

Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste.

Diagnosis

When symptoms are severe or not relieved by the treatments need more complete diagnostic evaluation.

Endoscopy (Esophago-gastroscopy) is an important procedure. A small lighted tube with a tiny video camera on the end (endoscope) is passed through mouth into the esophagus (food pipe) and stomach (food bag) to see any ill-effect of acid like inflammation or irritation of the tissue lining the esophagus (esophagitis). If the findings of the endoscopy are abnormal or questionable, biopsy (removing a small sample of tissue) from the lining of the esophagus.

Esophageal manometric and impedance studies -- pressure measurements of the esophagus -- occasionally help identify low pressure in the LES or abnormalities in esophageal muscle contraction.

For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the esophagus through pH testing. Testing pH monitors the acidity level of the esophagus and symptoms during meals, activity, and sleep. Newer techniques of long-term pH monitoring are improving diagnostic capability in this area.

Complications

Complications

Long-standing inflammation of esophagus can lead to following complications

  •   Esophageal Ulcer: Stomach acid can severely erode tissues in the esophagus, causing an open sore to form. The esophageal ulcer may bleed, cause pain and make swallowing difficult.
  •   Esophageal Stricture/ Stenosis (Narrowing of the esophagus): Damage to cells in the lower esophagus from acid exposure leads to formation of scar tissue. The scar tissue narrows the food pathway, causing difficulty swallowing.
  •   Precancerous changes to the esophagus (Barrett's esophagus): In Barrett's esophagus, the color and composition of the tissue lining the lower esophagus change. These changes are associated with an increased risk of esophageal cancer. The risk of cancer is low, but need regular endoscopy exams to look for early warning signs of esophageal cancer.
Treatment

Medical Treatment

Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the esophagus from refluxed materials.

Life style, dietary modification along with medication are cornerstone of medical treatment.

  •   Avoiding foods and beverages that can weaken the LES is often recommended. These foods include chocolate, peppermint, fatty foods, coffee, and alcoholic beverages.
  •   Foods and beverages that can irritate a damaged esophageal lining, such as citrus fruits and juices, tomato products, and pepper, should also be avoided if they cause symptoms.
  •   Decreasing the size of portions at mealtime may also help control symptoms.
    • Eating meals at least 2 to 3 hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially.

Life Style Modifications

  •   Weight reduction: Overweight often worsens symptoms. Weight loss is found to improve symptoms.
  •   Stop Cigarette : Cigarette smoking weakens the LES. Stopping smoking is important to reduce GERD symptoms.
  •   Elevation of Bed: Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimize reflux of stomach contents into the esophagus. Do not use pillows to prop yourself up; that only increases pressure on the stomach.

Medicine

  •   Patients who do not respond well to lifestyle changes or medications or
  •   those who continually require medications to control their symptoms
  •   those develops complications of GERD Like Ulcer, Bleeding, Baretts Esophagus, Stricture or rarely Cancer etc

Surgical Treatment

  •   Medicine (H2 blockers & Proton pump Inhibitors) that block secretion of acid is one the way to lower acid level in stomach thus minimises the reflux.
  •   Medicine that increases the strength of the Lower Esophageal Sphincter (LES) and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal (GI) tract, is also advised to get good response.
Know about GERD Surgery

Surgery now a day used to treat GERD is known as Laparoscopic anti-reflux surgery (medically called as Laparoscopic Nissen Fundoplication). This surgery involves reinforcing the valve between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus.

In a laparoscopic procedure, surgeons use small incisions to enter the abdomen through cannulas (narrow tube-like instruments). The laparoscope, which is connected to a tiny video camera, is inserted through the small incision, giving the surgeon a magnified view of the patients internal organs on a television screen.

The entire operation is performed inside after the abdomen is expanded by inflating gas into it.


Laparoscopic Fundoplication Surgery

Laparoscopic Fundoplication Surgery

Preparation for Surgery

Our expert team members shall help you to prepare you for surgery.

Pre-operative testing

in most cases, you will need some tests before your surgery. The tests routinely used include:

  •   Blood tests to measure your blood counts, your risk of bleeding or infection, and how well your liver and kidneys are working.
  •   Chest x-ray and ECG (electrocardiogram) to check your lungs and your hearts electrical system.

Anaesthetic Assessment before Surgery:

Our expert team of Anaesthetist will ask you questions pertaining to your health and to assess your fitness for surgery. You are requested to tell them in detail about your current and past medical ailments, allergic reactions you've had in the past and current medicines that you are taking like blood thinning medicine. This medicine should be stopped prior to surgery to minimize the risk of bleeding during /after surgery.

Informed Consent

Informed consent is one of the most important parts of getting ready for surgery. It is a process during which you are told about all aspects of the treatment before you give written permission to perform the surgery.

Getting ready for Surgery

Depending on the type of operation you have, there may be things you need to do to be ready for surgery:

  •   Emptying your stomach and bowels (digestive tract) is important. Vomiting while under anaesthesia can be very dangerous because the vomitus could get into your lungs and cause an infection. Because of this, you will be asked to not eat or drink anything starting the night before the surgery or atleast 6 hours before surgery.
  •   Laxative: You may also be asked to use a laxative or an enema to make sure your bowels are empty.
  •   Shaving of Operative part: You need to have an area of your body shaved to keep hair from getting into the surgical cut (incision). The area will be cleaned before the operation to reduce the risk of infection.
Anaesthesia

Anaesthesia is the use of drugs to make the body unable to feel pain for a period of time. General anaesthesia puts you into a deep sleep for the surgery. It is often started by having you breathe into a face mask or by putting a drug into a vein in your arm. Once you are asleep, an endotracheal or ET tube is put in your throat to make it easy for you to breathe. Your heart rate, breathing rate, and blood pressure (vital signs) will be closely watched during the surgery. A doctor watches you throughout the procedure and until you wake up. They also take out the ET tube when the operation is over. You will be taken to the recovery room to be watched closely while the effects of the drugs wear off. This may take hours. People waking up from general anaesthesia often feel "out of it" for some time. Things may seem hazy or dream-like for a while. Your throat may be sore for a while from the endotracheal (ET) tube.


Recovery from Surgery

Pain

You may feel pain at the site of surgery. We aim to keep you pain free after surgery with the help of latest and most effective technique or analgesic (pain relieving medicine).

Eating and Drinking

You will be allowed orally liquids once you recover from effect of anaesthesia medicine and you don't have nausea or vomiting. Gradually you can add soft to normal diet.

Activity

Our health care team will try to have you move around as soon as possible after surgery. You are encouraged to get out of bed and walk the same day. While this may be hard at first, it helps speed your recovery. It also helps your circulation and helps prevent blood clots from forming in your legs.

Going home

Once you are eating and walking, and then you are ready to go home, in most case in next day following surgery. Before leaving for home our health care team shall give you detailed guidance regarding diet, activities, medications & further plan of treatment

Risks and side effects of surgery

There are risks that go with any type of medical procedure and surgery is no longer an exception. Success of surgery depends upon 3 factors: type of disease/surgery, experience of surgeon and overall health of patients. What's important is whether the expected benefits outweigh the possible risks.

Complications in major surgical procedures include:

Complications related to Anaesthesia:Reactions to drugs used (anesthesia) or other medicines. Although rare, these can be serious because they can cause dangerously low blood pressures.

Complications related to underlying medical illness like heart disease, diabetes, kidney disease, obesity, malnutrition.

Complications related to Specific Operations: Injury to the near by organs, bleeding and infection. You are encouraged with discuss in detail with our health care team before you give your consent for surgery.

Conversion to open surgery: In a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs (appendix) effectively. Factors that may increase the possibility of converting to the open procedure may include perforated & densely adherent appendix to nearby organ, obesity, a history of prior abdominal surgery causing dense scar tissue, or bleeding problems during the operation. The decision to convert to an open procedure is strictly based on patient safety.

Side effect of Surgery

Studies have shown that the vast majority of patients who undergo the procedure are either symptom-free or have significant improvement in their GERD symptoms.

Long-term side effects to this procedure are generally uncommon. Some patients develop temporary difficulty swallowing immediately after the operation. This usually resolves within one to three months after surgery. Occasionally, patients may require a procedure to stretch the esophagus (endoscopic dilation) or rarely re-operation. The ability to belch and or vomit may be limited following this procedure. Some patients report stomach bloating. Rarely, some patients report no improvement in their symptoms.

Life After Surgery

Nutrition

Our health care team shall advise you in detail regarding dietary habits, Briefly, your diet begins with liquids followed by gradual advance to solid foods.

Exercise

Patients are encouraged to engage in light activity while at home. You will be able to get back to your normal activities within a short amount of time (week).

Follow up

You may be advised to see our health care team after 1 week to assess your progress and to address your problems.

Life After Surgery

Nutrition

Our health care team shall advise you in detail regarding dietary habits, Briefly, your diet begins with liquids followed by gradual advance to solid foods.

Exercise

Patients are encouraged to engage in light activity while at home. You will be able to get back to your normal activities within a short amount of time (week).

Follow up

You may be advised to see our health care team after 1 week to assess your progress and to address your problems.

ESOPHAGUS



Introduction

The esophagus is a muscular tube in the chest. It's about 10 inches (25 centimeters) long.

This organ is part of the digestive tract. Food moves from the mouth through the esophagus to the stomach.

The wall of the esophagus has several layers:

  1. Inner layer or lining: The lining (mucosa) of the esophagus is wet, which helps food to pass to the stomach.
  2. Submucosa: Glands in the submucosa layer make mucus, which helps keep the lining of the esophagus wet.
  3. Muscle layer: The muscles push food down to the stomach.
  4. Outer layer: The outer layer covers the esophagus.

Cancer Cells

Cancer begins in cells, the building blocks that make up all tissues and organs of the body, including the esophagus.

Normal cells in the esophagus and other parts of the body grow and divide to form new cells as they are needed. When normal cells grow old or get damaged, they die, and new cells take their place.

Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor.

A tumor in the esophagus can be benign (not cancer) or malignant (cancer):



Benign tumors:

  1. Are rarely a threat to life
  2. Don't invade the tissues around them
  3. Don't spread to other parts of the body
  4. Can be removed and don't usually grow back

Malignant tumors (cancer of the esophagus):

  1. May be a threat to life
  2. Can invade and damage nearby organs and tissues
  3. Can spread to other parts of the body
  4. Sometimes can be removed but may grow back

Esophageal cancer cells can spread by breaking away from an esophageal tumor. They can travel through blood vessels or lymph vessels to reach other parts of the body. After spreading, cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues.

When esophageal cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the original tumor. For example, if esophageal cancer spreads to the liver, the cancer cells in the liver are actually esophageal cancer cells. The disease is metastatic esophageal cancer, not liver cancer. For that reason, it is treated as cancer of the esophagus, not liver cancer.

Types of Esophageal Cancer

The two most common types are named for how the cancer cells look under a microscope:

  1. AdenoCarcinoma (AC): Usually, AC tumors are found in the lower part of the esophagus, near the stomach. AC of the esophagus may be related to having acid reflux (the backward flow of stomach acid), having a disease of the lower esophagus known as Barrett esophagus, or being obese.
  2. Squamous Cell Carcinoma (SCC) Usually, SCC tumors are found in the upper part of the esophagus. SCC of the esophagus may be related to being a heavy drinker of alcohol or smoking tobacco.

Tests

After you learn that you have cancer of the esophagus, you may need other tests to help with making decisions about treatment.

Tumor Grade Test

The tumor tissue that was removed during your biopsy procedure can be used in lab tests. The pathologist studies tissue samples under a microscope to learn the grade of the tumor. The grade tells how different the tumor tissue is from normal esophagus tissue.

Tumors with higher grades tend to grow faster than those with lower grades. They are also more likely to spread. Doctors use tumor grade along with other factors to suggest treatment options.

For more about tumor grade, see the NCI fact sheet Tumor Grade.

Risk Factor

Adeno-carcinoma of Esophagus

Increasing incidence of acid reflux: Intake of caffeine, fats, and acidic and spicy foods all lead to increase in reflux of acid and damages the inner lining (mucosa) of esophagus, called as Barretts esophagus. If this damage is long standing over a time of year, this mucosa turn into cancer.

Squamous Cell carcinoma of Esophagus

  1. Alcohol
  2. Smoking
  3. Plummer-Vinson syndrome, a disease of iron and vitamin deficiency that results in atrophy of the oropharyngeal and esophageal mucosa.
  4. Achalasia cardia
  5. Esophageal diverticula
Symptoms

The symptoms of esophageal cancer vary with the stage of the disease. Early-stage cancers may be asymptomatic or simulate the symptoms of reflux disease. Heartburn, regurgitation, and indigestion are symptoms of reflux, but cancer may be underlying cause for these symptoms. Usually patients with esophageal cancer present with dysphagia (difficulty in swallowing of solid initially and later on to liquid) and weight loss. These symptoms usually indicate advanced disease.

Choking, coughing, and aspiration from a tracheoesophageal fistula (un-natural communication between food pipe and wind pipe), as well as hoarseness and vocal cord paralysis are ominous signs of advanced disease.

Diagnosis

If you have symptoms that suggest esophagus cancer, your doctor will check to see whether they are due to cancer or to some other cause. Your doctor may refer you to a gastroenterologist, a doctor whose specialty is diagnosing and treating digestive problems.

Your doctor will ask about your personal and family health history. You may have blood or other lab tests. You also may have

  1. Physical exam: Your doctor feels your abdomen for fluid, swelling, or other changes. Your doctor also will check for swollen lymph nodes.
  2. Endoscopy: Your doctor uses a thin, lighted tube (endoscope) to look into your stomach. Your doctor first numbs your throat with an anesthetic spray. You also may receive medicine to help you relax. The tube is passed through your mouth and esophagus to the stomach.
  3. Biopsy: An endoscope has a tool for removing tissue. Your doctor uses the endoscope to remove tissue from the stomach. A pathologist checks the tissue under a microscope for cancer cells. A biopsy is the only sure way to know if cancer cells are present.


Staging

Staging tests can show the stage (extent) of esophageal cancer, such as whether cancer cells have spread to other parts of the body.

When cancer of the esophagus spreads, cancer cells are often found in nearby lymph nodes. Esophageal cancer cells can spread from the esophagus to almost any other part of the body, such as the liver, lungs, or bones.

Staging tests may include...

  1. CT scan: Your doctor may order a CT scan of your chest and abdomen. An x-ray machine linked to a computer will take a series of detailed pictures of these areas. You'll receive contrast material by mouth and by injection into a blood vessel in your arm or hand. The contrast material makes abnormal areas easier to see. The pictures can show cancer that has spread to the liver, lungs, bones, or other organs.
  2. PET scan: Your doctor may use a PET scan to find cancer that has spread. You'll receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in the body. Because cancer cells use sugar faster than normal cells, areas with cancer cells look brighter on the pictures. The pictures can show cancer that has spread to the lymph nodes, liver, or other organs.
  3. EUS:Â An EUS (endoscopic ultrasound) can show how deeply the cancer has invaded the wall of the esophagus. It can also show whether cancer may have spread to nearby lymph nodes. Your doctor will pass a thin, lighted tube (endoscope) through your mouth to your esophagus. A probe at the end of the tube sends out high-energy sound waves. The waves bounce off tissues in your esophagus and nearby organs, and a computer creates a picture from the echoes. During the exam, the doctor may take tissue samples of lymph nodes.

Stages

Doctors describe the stages of esophageal cancer using the Roman numerals I, II, III, and IV. Stage I isearly-stage cancer, and Stage IV is advanced cancer that has spread to other parts of the body, such as the liver.

The stage of cancer of the esophagus depends mainly on...

  1. How deeply the tumor has invaded the wall of the esophagus
  2. The tumor's location (upper, middle, or lower esophagus)
  3. Whether esophageal cancer cells have spread to lymph nodes or other parts of the body

Stages I and II of Adenocarcinoma of the Esophagus

Stage IA

Cancer has grown through the inner layer and invades the wall of the esophagus. The grade is 1 or 2.

Stage IB

Cancer has invaded the wall of the esophagus and is grade 3. Or, cancer has invaded more deeply into the muscle layer of the esophagus, and the grade is 1 or 2.

Stage IIA

Cancer has invaded the muscle layer of the esophagus, and the grade is 3.

Stage IIB

Cancer has invaded the outer layer of the esophagus. Or, cancer has not invaded the outer layer, but cancer cells are also found in one or two nearby lymph nodes.

Stages I and II of Squamous Cell Cancer of the Esophagus

Stage IA

Cancer has grown through the inner layer and invaded the wall of the esophagus. The grade is 1.

Stage IB

Cancer has invaded the wall of the esophagus and is grade 2 or 3. Or, cancer is found in the lower part of the esophagus, it has invaded the muscle layer or outer layer of the esophagus, and the grade is 1.

Stage IIA

Cancer is found in the upper or middle part of the esophagus, it has invaded the muscle layer or outer layer of the esophagus, and the grade is 1. Or, cancer is found in the lower part of the esophagus, it has invaded the muscle layer or outer layer of the esophagus, and the grade is 2 or 3.

Stage IIB

Cancer is found in the upper or middle part of the esophagus, it has invaded the muscle layer or outer layer of the esophagus, and the grade is 2 or 3. Or, cancer has not invaded the outer layer, and cancer cells are found in one or two nearby lymph nodes.

Stages III and IV of Esophageal Cancer (Both Types)

Stage IIIA

Stage IIIA is one of the following:

  1. Cancer has not invaded the outer layer, and cancer cells are found in 3 to 6 nearby lymph nodes.
  2. Or, cancer has invaded the outer layer of the esophagus, and cancer cells are also found in 1 or 2 nearby lymph nodes.
  3. Or, cancer extends through the esophageal wall and has invaded nearby tissues, such as thediaphragm or pleura. No cancer cells are found in lymph nodes.

Stage IIIB

Cancer has invaded the outer layer of the esophagus, and cancer cells are found in 3 to 6 nearby lymph nodes.

Stage IIIC

Stage IIIC is one of the following:

  1. Cancer has invaded tissues near the esophagus, and cancer cells are found in up to 6 nearby lymph nodes.
  2. Or, cancer cells are found in 7 or more nearby lymph nodes.
  3. Or, the cancer can't be removed by surgery because the tumor has invaded the trachea or other nearby tissues.

Stage IV

The esophageal cancer has spread to other parts of the body, such as the liver, lungs, or bones.

Treatment

People with cancer of the esophagus have many treatment options. Treatment options include...

  1. Surgery
  2. Radiation therapy
  3. Chemotherapy
  4. Targeted therapy

You and your doctor will develop a treatment plan. The treatment that's right for you depends mainly on the type and stage of esophageal cancer. You'll probably receive more than one type of treatment. For example, radiation therapy and chemotherapy may be given before or after surgery.

Surgery

Surgery may be an option for people with early-stage cancer of the esophagus. Usually, the surgeon removes the section of the esophagus with the cancer, a small amount of normal tissue around the cancer, and nearby lymph nodes. Sometimes, part or all of the stomach is also removed.

If only a very small part of the stomach is removed, the surgeon usually reshapes the remaining part of the stomach into a tube and joins the stomach tube to the remaining part of the esophagus in the neck or chest. Or, a piece of large intestine or small intestine may be used to connect the stomach to the remaining part of the esophagus.

If the entire stomach needs to be removed, the surgeon will use a piece of intestine to join the remaining part of the esophagus to the small intestine.

During surgery, the surgeon may place a feeding tube into your small intestine. This tube helps you get enough nutrition while you heal.

You may have pain from the surgery. However, your health care team will give you medicine to help control the pain. Before surgery, you may want to discuss the plan for pain relief with your health care team. After surgery, they can adjust the plan if you need more pain relief.

Your health care team will watch for pneumonia or other infections, breathing problems, bleeding, food leaking into the chest, or other problems that may require treatment.

The time it takes to heal after surgery is different for everyone. Your hospital stay may be a week or longer, and your recovery will continue after you leave the hospital.

Radiation Therapy

Radiation therapy is an option for people with any stage of esophageal cancer. The treatment affects cells only in the area being treated, such as the throat and chest area.

Radiation therapy may be given before, after, or instead of surgery. Chemotherapy is usually given along with radiation therapy.

Radiation therapy for esophageal cancer may be given to...

  1. Destroy the cancer
  2. Help shrink the tumor so that you can swallow more easily
  3. Help relieve pain from cancer that has spread to bone or other tissues

Doctors use two types of radiation therapy to treat esophageal cancer. Some people receive both types:

  1. Machine outside the body: The radiation comes from a large machine. This is called external radiation therapy. The machine aims radiation at your body to kill cancer cells. It doesn't hurt. You'll go to a hospital or clinic, and you'll lie down on a treatment table. Each treatment session usually lasts less than 20 minutes. Treatments are usually given 5 days a week for several weeks.
  2. Radioactive material inside the body (brachytherapy): The doctor numbs your throat with an anesthetic spray and gives you medicine to help you relax. The doctor puts a tube into your esophagus. The radiation comes from the tube. After the tube is removed, no radioactivity is left in your body. Usually, one treatment session is needed. Because the treatment session lasts one to two days, you'll probably stay in a special room at the hospital.

Chemotherapy

Most people with esophageal cancer get chemotherapy. It may be used alone or with radiation therapy.

Chemotherapy uses drugs to kill cancer cells. The drugs for cancer of the esophagus are usually given directly into a vein (intravenously) through a thin needle.

Targeted Therapy

People with esophageal cancer that has spread may receive a type of treatment called targeted therapy. This treatment can block the growth and spread of esophageal cancer cells.

Targeted therapy for cancer of the esophagus is usually given intravenously. The treatment enters the bloodstream and can affect cancer cells all over the body.

During treatment, your health care team will watch you for side effects. You may get diarrhea, belly pain, heartburn, joint pain, tingling arms and legs, or heart problems. Most side effects usually go away after treatment ends.

Overview of Cancer Surgery

Goal of Cancer Surgery

Depending on your cancer type and stage, our goals for treatment are:

  1. Cure : This is the most important goal of cancer surgery. In fact as a cancer patient you are also strongly willing to have cure of cancer for forever. For most of the Liver & Gastro-intestinal cancers perhaps surgery is the first step for cure. Radiation &/or Chemotheray may be advised as an additional tool to achieve this goal.
  2. Control : If your cancer is at a later stage or if previous treatments have been unsuccessful, we aim to control your cancer by removing as much as safely possible. Once you recover from surgery, radiation or chemotherapy is advised as important tool to control your cancer.
  3. Comfort : If you have an advanced stage of cancer or one that hasn't responded to treatments and having symptoms because of tumor i.e pain, jaundice, vomiting, bleeding either in vomitus or in stool, then our multi-specialist team work together to sure you are free of pain and other symptoms.
Role of Surgery for Cancer treatment

Surgery can be done for many reasons for treatment of cancer.

Curative Surgery
  1. Curative surgery is done when cancer is found in only one area, and it’s likely that all of the cancer can be removed. In this case, curative surgery can be the main treatment. It may be used alone or along with chemotherapy or radiation therapy, which can be given before or after the operation.
Diagnostic & Staging Surgery
  1. This type of surgery is used to take out a piece of tissue (biopsy) to find out if cancer is present or what type of cancer it is. The diagnosis of cancer is made by looking at the cells under a microscope. Staging surgery is done to find out how much cancer there is and how far it has spread. The physical exam and the results of lab and imaging tests are used to figure out the clinical stage of the cancer. But the surgical stage (also called the pathologic stage) is usually a more exact measure of how far the cancer has spread. Examples of surgical procedures commonly used to stage cancers, like laparoscopy or laparotomy.
Palliative Surgery
  1. This type of surgery is used to treat problems caused by advanced cancer. It is not done to cure the cancer. For example, cancers of intestine may grow large enough to block off (obstruct) the intestine, or tumor is bleeding and unable to control bleed by medical/endoscopic technique. If this happens, surgery can be used to remove the blockage/control bleeding.

Approach for Surgery:

How surgery is performed? (Special surgery techniques): Open Or Laparoscopic

Open Surgery:
  1. It is the Gold Standard approach for Liver & Gastro-Intestinal cancer. An incision is given on the belly depending upton the underlying location of tumor so that surgeon can directly approach the cancer on cutting the belly. Open Surgery help to remove tumor safely if its adherent to near by blood vessels or organ, that is otherwise difficult in laparoscopic surgery.
Laparoscopic Surgery
  1. A laparoscope is a long, thin, flexible tube that can be put through a small cut (incision) to look inside the body. In recent years, doctors have found that by creating small holes and using special instruments, the laparoscope can be used to perform surgery without making a large cut. This can help reduce blood loss during surgery and pain afterward. It can also shorten hospital stays and allow people to heal faster.
  2. The role of laparoscopic surgery in cancer treatment is not yet clear. Doctors are now studying whether it is safe and effective to use laparoscopic surgeries for cancers of the stomach, colon, rectum & liver. It may prove to be as safe and work as well as standard surgery while cutting less and causing less damage to healthy tissues (being less invasive).

Biopsy of Cancer before Surgery

Biopsy is procedure to confirm the presence of cancer. It’s not essential before surgery. Usually biopsy is performed when 1. Suspicion is cause other than cancer, 2. When surgery cannot be done for cancer due to advanced stage of cancer or 3. Patient is unfit to undergo surgery. In these situation, biopsy guides for further therapy.

If all investigations suggest that cancer can be removed in totality from body, then biopsy can be avoided in to minimize the risk of spillage of cancer cell during biopsy procedure.

There is variety of way to perform biopsies:

Fine Needle Aspiration (FAN) biopsy
  1. Fine needle aspiration (FNA) uses a very thin needle attached to a syringe to pull out small bits of tissue. The needle is guided into the tumor by looking at it using an imaging test, like an ultrasound or CT scan.
  2. The main advantage of FNA is that there is no need to cut through the skin, so there is no surgical incision.
  3. A drawback is that in some cases the needle can’t take out enough tissue for an exact diagnosis. A more invasive type of biopsy (one that involves larger needles or a cut in the skin) may then be needed.
Core Needle biopsy
  1. This type of biopsy uses a larger needle to take out a core of tissue and done under guidance of imaging test like an ultrasound or CT scan. The advantage of core biopsy is that it usually collects enough tissue to find out whether the tumor is cancer.
Excisional or Incisional biopsy
  1. For these biopsies, the surgeon remove the entire tumor (excisional biopsy) or a small part of the tumor (incisional biopsy).
Preparation for Surgery

Our expert team members shall help you to prepare you for surgery. You are strongly advised to stop smoking, stop drinking alcohol, try to improve your diet, lose weight, or actively exercise before surgery.

Pre-operative testing

In most cases, you will need some tests before your surgery. The tests routinely used include:

  1. Blood tests to measure your blood counts, your risk of bleeding or infection, and how well your liver and kidneys are working. Your blood group type is also be checked in case you need blood transfusions during the operation.
  2. Chest x-ray and ECG (electrocardiogram) to check your lungs and your heart’s electrical system.
  3. USG/CT scans/ MRI to look at the size and location of the tumors and see if the cancer looks like it has spread to nearby tissues.
Anaesthetic Assessment before Surgery:

Our expert team of Anaesthetist will ask you questions pertaining to your health and to assess your fitness for surgery. You are requested to tell them in detail about your current and past medical ailments, allergic reactions you’ve had in the past and current medicines that you are taking like blood thinning medicine. This medicine should be stopped 1 week prior to surgery.

Informed Consent

Informed consent is one of the most important parts of “getting ready for surgery”. It is a process during which you are told about all aspects of the treatment before you give your doctor written permission to do the surgery.

Getting ready for Surgery

Depending on the type of operation you have, there may be things you need to do to be ready for surgery:

  1. Emptying your stomach and bowels (digestive tract) is important. Vomiting while under anaesthesia can be very dangerous because the vomit could get into your lungs and cause an infection. Because of this, you will be asked to not eat or drink anything starting the night before the surgery.
  2. Laxative: You may also be asked to use a laxative or an enema to make sure your bowels are empty.
  3. Shaving of Operative part: You need to have an area of your body shaved to keep hair from getting into the surgical cut (incision). The area will be cleaned before the operation to reduce the risk of infection.
Anaesthesia

Anaesthesia is the use of drugs to make the body unable to feel pain for a period of time. General anaesthesia puts you into a deep sleep for the surgery. It is often started by having you breathe into a face mask or by putting a drug into a vein in your arm. Once you are asleep, an endotracheal or ET tube is put in your throat to make it easy for you to breathe. Your heart rate, breathing rate, and blood pressure (vital signs) will be closely watched during the surgery. A doctor watches you throughout the procedure and until you wake up. They also take out the ET tube when the operation is over. You will be taken to the recovery room to be watched closely while the effects of the drugs wear off. This may take hours. People waking up from general anaesthesia often feel "out of it" for some time. Things may seem hazy or dream-like for a while. Your throat may be sore for a while from the endotracheal (ET) tube.


Recovery from Surgery

Your recovery right after surgery depends on many factors, including your state of health before the operation and how extensive the operation was performed.

Pain

You may feel pain at the site of surgery. We aim to keep you pain free after surgery with the help of latest and most effective technique or analgesic (pain relieving medicine).

Tube/ Drains
  1. You may also have Ryle’s Tube (tube going through nose to stomach) that drain out intestinal fluid. This tube helps to relieve nausea and vomiting after surgery and usually removed 1-2 day after surgery.
  2. You may also have “Tube” (called a Foley catheter) draining urine from your bladder into a bag. This will be taken out soon after surgery, once you are comfortable enough to go to bathroom.
  3. You may have a tube or tubes (called Drains) coming out of the surgical opening in your skin (incision site). Drains allow the excess fluid that collects at the surgery site to leave the body. Drain tube will also be removed once they stop collecting fluid, usually a few days after the operation.
Leg Stocking / Compression boot

As you are remains in bed on day of surgery, circulation of blood in leg become sluggish that may increase possibility of thrombo-embolism. To minimise it, you will be wearing leg stocking/ pneumatic compression boot to improve your leg circulation thus minimising the risk of thrombolism.

Eating and Drinking

You may not feel much like eating or drinking, but this is an important part of the recovery process. Our health care team may start you out with ice chips or clear liquids. The stomach and intestines (digestive tract) is one of the last parts of the body to recover from the drugs used during surgery. You will need to have signs of stomach and bowel activity before you will be allowed to eat. You will likely be on a clear liquid diet until this happens. Once it does, you may get to try solid foods.

Activity
  1. Our health care team will try to have you move around as soon as possible after surgery. They may even have you out of bed and walking the same day. While this may be hard at first, it helps speed your recovery by getting your digestive tract moving. It also helps your circulation and helps prevent blood clots from forming in your legs.
  2. Our team shall also encourage you to do deep breathing exercises. This helps fully inflate your lungs and reduces the risk of pneumonia. You are advised to take deep breaths and cough every hour to help prevent lung infections. You will use an incentive spirometer (a small device used in breathing exercises to prevent complications after major surgery) 10-15 times every hour.
Going home

Once you are eating and walking, all tube/drains placed during surgery are removed, and then you may be ready to go home. Before leaving for home our health care team shall give you detailed guidance regarding diet, activities, medications & further plan of treatment.

Risks and side effects of surgery

There are risks that go with any type of medical procedure and surgery is no longer an exception. Success of surgery depends upon 3 factors: type of disease/surgery, experience of surgeon and overall health of patients. What’s important is whether the expected benefits outweigh the possible risks.

Doctors have been performing surgeries for a very long time. Advances in surgical techniques and our understanding of how to prevent infections have made modern surgery safer and less likely to damage healthy tissues than it has ever been. Still, there’s always a degree of risk involved, no matter how small. Different procedures have different kinds of risks and side effects. Be sure to discuss the details of your case with our health care team, who can give you a better idea about what your actual risks are. During surgery, possible complications during surgery may be caused by the surgery itself, the drugs used (anesthesia), or an underlying disease. Generally speaking, the more complex the surgery is the greater the risk. Complications in major surgical procedures include:


  1. Complications related to Anaesthesia : Reactions to drugs used (anesthesia) or other medicines. Although rare, these can be serious because they can cause dangerously low blood pressures. Your doctors will watch your heart rate, breathing rate, blood pressure, and other signs throughout the procedure to look for this.
  2. Complications related to underlying medical illness like heart disease, diabetes, kidney disease, obesity, malnutrition.
    1. Lung : Pneumonia, Atelectasis (collapse of lung), effusion (fluid in chest) can occur, especially in patients with reduced lung function, such as smokers. Doing deep breathing exercises as soon as possible after surgery helps lessen this risk.
    2. Thrombosis (blood clot) in leg & embolism (blood clot) in lung : Blood clots can form in the deep veins of the legs after surgery, especially if a person stays in bed for a long time. Such a clot can become a serious problem if it breaks loose and travels to another part of the body, such as a lung. This is a big reason why you will be encouraged to get out of bed to sit, stand, and walk as soon as possible.
    3. Cardiovascular : Myocardial infarction (heart attach), Arrhythmia (irregular heart beat), Stroke (cerebro-vascular accidents).
    4. Kidney & urinary tract infection, acute kidney failure if patient has uncontrolled/non-responding infection.
  3. Complications related to Specific Operations
    1. There are specific complications related to type of surgery. You are encouraged with discuss in detail with our health care team before you give your consent for surgery.
    2. Bile leak
    3. Bleed
  4. Complications related to Major Surgery
    1. Infection : Infection at the site of the wound, lung and urinary infection. Infection risk is more if intestine is perforated before surgery, operated for colon and rectum, stent in placed in bile duct to relieve jaundice or intestinal joint is leaking.
    2. Bleeding : The risk of bleeding during or after surgery is more if patient taking blood thinning medicine till day of surgery or having liver dysfunction. Bleeding during surgery that may cause you to need blood transfusions. There is a risk of certain problems with transfusions, some of them serious. Still, some operations involve a certain amount of controlled blood loss. Bleeding can happen either inside the body (internally) or outside the body (externally). It can occur if a blood vessel sealed during surgery opens up or if a wound opens up. Serious bleeding may cause the person to need another operation to find the source of the bleeding and stop it.
    3. Leakage from anastomosis (joint of anastomosis) & fluid collection in tummy.
    4. Blockage of intestine (Intestinal obstruction)
Life After Surgery

Nutrition
  1. Following treatment, you may feel change in your taste. This improves over a time and we encourage having health food habit like fresh vegetables, fruits and high protein diet.
Exercise
  1. Along with healthy food habits, we also encourage for exercise. Exercise improves your health in different ways: It improves your heart and circulation, makes your muscles stronger & makes you feel happier. You should do your regular activities like walking, and rather increase day by day. Weight lifting and strenuous exercise are avoided for initial 2-3 months.
Follow up care
  1. You'll need regular check-ups after treatment for liver cancer. This help to find out any change in your recovery. Sometimes liver cancer comes back after treatment. Our health care team will check for return of cancer. Checkups may include a physical exam, blood tests, ultrasound / CT scan.
  2. If you have any health problems between checkups, you should contact our health care team. Report to our health care team, if you have any redness/ swelling or discharge of any type of fluid from your operative incision site, pain abdomen, vomiting or fever, breathing difficulty etc.

Esophagus Surgery







Esophageal Diverticulum
Dr. Avinash Tank, Surgeon
Corrosive Injury
Dr. Avinash Tank, Surgeon

Shalby Hospitals,
Opposite Karnavati Club,
SG Road, Ahmedabad-380015,
Gujarat, India.

+91 88660 20505

contact@dravinashtank.in



Copyright © 2017 Dr. Avinash Tank. All Rights Reserved. Design by City Business