Esophageal Tumours

Benign esophageal tumors such as the leiomyoma (benign smooth muscle tumor), hemangioma (benign vascular tumor) or fibroma (polyps) are uncommon. As it is difficult to make a reliable distinction between a benign and malignant tumor, benign tumors are usually surgically removed. If a definite diagnosis was possible, in a small tumor, the procedure can be done endoscopically. Based on their histological findings, a distinction can be made between adenocarcinoma and squamus cell carcinoma.

Causes

Consumption of concentrated alcohol and smoking are considered to be the risk factors for esophageal carcinomas. Barrett's syndrome due to reflux esophagitis, lays the foundation for the development of adenocarcinoma. Due to non-specific swallowing difficulties, malignant tumors are often not discovered early on.

 

Diagnostic Procedures

Diagnosis is done with an endoscopy and examination of tissue samples. An endosonography and a contrast medium imaging is sometimes done for ascertaining the type and degree of the tumour (tumour staging) Computer tomography (CT scan) of the chest cavity and abdomen in cases where metastases are suspected completes the full diagnosis. When there are clinical indications of metastases in the bones a scintigraphy of the skeleton is done.

 

Treatment

As a matter of principle, if the tumor hasn't spread (metastases) or if no other serious disease (e.g. liver cirrhosis) is present that makes surgery too risky, the option of resection is considered in all cases of malignant tumors or even in those where there is a suspicion of malignancy

Surgical Therapy

The surgical procedure depends on the location and size of the tumor. Benign tumors, which often grow into the lumen, can be removed either via endoscopy or locally, after which the esophagus is sutured. Malignant tumors are radically removed in such a way that the whole affected part of the esophagus and a bit of the unaffected section is removed making sure that the cut margins are free of the tumour.

The operation often starts with a horizontal incision to open the abdomen (laparotomy). After any spreading (metastasis) into the liver or abdominal organs has been excluded, the stomach and the lower section of the esophagus through the diaphragm are looked at. It is often possible to remove tumors, which are very low in the esophagus. Once in awhile a neck incision (collar incision) is needed and the whole esophagus can be reached and removed. Tumors located in the middle section of the esophagus require that the chest cavity also be opened to ensure access to and radical removal of the esophagus.

The Oesophagus is removed only when it has been determined that the tumor can be completely removed. In such cases, the stomach can be used as a substitute to the Oesophagus if (delete 'If') its blood circulation is good. To achieve this a special method developed by Professor Markus W. Büchler is performed. (Fundus Rotation Plasty). This method makes it possible to construct a sufficiently long tube by drawing the stomach up to the remaining esophagus so that even in the case of tumors in the upper esophagus, it can be attached to the remaining esophagus or to the larynx. If the stomach cannot be used, a colon interposition would be done. The right section of the large intestine or the transverse colon with part of the left colon can be used. The choice is again based on circulation. The chosen colon section is then transferred along with its feeding vessels to the chest cavity and is sutured at the top to the remaining esophagus and at the bottom to the remaining stomach. Rarely the small intestine can be used. When surgery is completed the patient will have a feeding tube into the stomach and drainage tubes in the chest and abdominal cavities.

 

Complications

The most feared complication is anastomotic insufficiency. This causes leakage of liquids or food into the adjacent tissue and inflammation. Small leakages can be treated with a drainage tube inserted from the inside through the esophagus or from the outside through the skin. Larger leakages with serious inflammation must be treated surgically and the surgery includes the removal of the substitute esophagus (drawn up stomach tube or intestine section), and the esophagus stump is lead to the outside in the neck area as a mucous fistula.

After a period of about 3 months, the continuity of the normal food passage can be restored with a transposition of a colon segment or small bowel to the cervical esophagus, in this worst case scenario.

 

Aftercare

Post operatively the patient is cared for in the intensive care unit. Particular attention is paid to cardio-vascular stabilization, monitoring of lung function, and pain therapy. When the patient is stable he/she is transferred out of intensive care, where mobilization is stressed. On the 5th day after surgery a contrast medium x-ray is done to check the condition of the anastomoses. If there is no leakage, oral food intake is gradually allowed (begin), starting at first with mashed food and then solids. If any complications are present, nutrition is achieved intravenously. Usually on the 3rd day after surgery one can start removing the drainage tubes. As soon as the wounds have healed the patient can be cared for on an out-patient basis. The out-patient aftercare depends on the disease being treated. Regular CT scans and if indicated, endoscopic examinations are done to exclude any relapses. If it was a malignant tumor chemotherapy can be now given.