Esophageal cancer is one of the common malignant tumors of digestive tract in China, and its incidence rate ranks 4th in China after stomach cancer, liver cancer and lung cancer. The incidence rate and mortality rate of esophageal cancer in China rank the first in the world, and about 300,000 people die of esophageal cancer in the world every year, and more than 150,000 people die of esophageal cancer in China every year, accounting for about 1/2. Because the symptoms of early esophageal cancer are mild, it is not easy to detect. Therefore, about 80% of patients are already in the middle and late stages when first diagnosed, and surgical treatment is still the main treatment means, but the overall 5-year survival rate of esophageal cancer is <10%. In order to improve the efficacy and survival of patients, new comprehensive treatment plans and advanced surgical treatment techniques are being explored continuously.
I. Symptoms of esophageal cancer.
1.Early symptoms
(1) Choking sensation of swallowing food: early symptoms are atypical and often include increased saliva and discomfort in swallowing, which can generally enter general food without affecting health. The occurrence of symptoms is often related to the patient’s mood swings.
(2) Pain or stuffy discomfort behind the sternum: about half of the patients complained of slight pain or stuffy discomfort behind the sternum when swallowing food, mostly pain is obvious when swallowing rough and hard food, hot food or food with irritation, pain is lighter when swallowing liquid and warm food, pain when swallowing food, pain is reduced or disappeared after eating, some others have heavy pain, which is persistent, and the patient’s self-perceived pain site is not consistent with the lesion in the esophagus.
(3) Foreign body sensation in the esophagus: Patients feel that there is something like rice grains or vegetable pieces attached to the wall of the esophagus, which cannot be swallowed and cannot be spit out, not related to eating.
(4) Dry throat: 1/3 of the patients complained of dryness and tightness in the throat, unfavorable swallowing of food or slight pain, especially into dry or rough food.
(5) The feeling of slow passage and retention of food, and the same feeling when drinking water. In addition, some patients have symptoms such as back sinking and belching. More than half of the patients have symptoms for more than one year, some for as long as four years, so it is clinically important to make correct diagnosis and take correct treatment for early esophageal cancer.
2.Middle and late stage symptoms
(1) Difficulty in swallowing: progressive difficulty in swallowing is the most typical symptom of middle and late stage esophageal cancer, starting from solid food cannot be swallowed smoothly, or swallowed after being washed with soup and water, followed by semi-liquid diet which is also obstructed, and finally there is difficulty in swallowing liquid diet. The degree of unfavorable swallowing is closely related to the type of pathology, with the constricted type and medullary type being more severe.
(2) Pain: Chest pain or back pain is one of the common symptoms of middle and late stage esophageal cancer, which is dull pain, hidden pain or burning pain, stabbing pain, and may be accompanied by heavy feeling. The pain is more common in ulcerated type and medullary type with ulcer.
(3) Emesis: incomplete or complete obstruction of the esophagus caused by esophageal changes starting from esophageal lesions, so that secretions are poorly drained and accumulate in the upper part of the esophageal stricture and are spit out after stimulating retroperistalsis of the esophagus.
(4) Neck and supraclavicular mass: It is a common sign of advanced esophageal cancer, and the mass is painless, progressively increasing, hard, mostly on the left side, but may be bilateral.
(5) Hoarseness: When tumor directly invades or metastases presses the laryngeal nerve, vocal cord paralysis occurs, resulting in hoarseness.
(6) Hemorrhage: When cancer tissue necrosis, ulceration or invasion of large blood vessels cause vomiting blood or black stool, and when tumor invades the aorta, it may cause hemorrhage and death.
(7) Dry cough: shortness of breath and dry cough may occur if the trachea is compressed, and choking cough when eating occurs if esophageal fistula is formed.
3.End-stage symptoms
(1) Widespread metastasis throughout the body with corresponding symptoms and signs, jaundice, ascites, abnormal liver function, dyspnea, cough, headache, coma, etc.
(2) Perforation of esophagus caused by tumor invasion of esophageal lining, esophage-tracheal fistula and esophage-mediastinal fistula.
(3) Complete obstruction, dehydration, electrolyte disorder, cachexia and systemic failure caused by tumor blocking esophagus.
Minimally invasive treatment of esophageal cancer
1.Minimally invasive treatment of early esophageal cancer
Minimally invasive endoscopic treatment techniques for early esophageal cancer can be broadly divided into two categories: one category is mucosal resection of cancerous tissue, i.e. Endoscopic esophageal mucosectomy, which has both diagnostic and therapeutic functions, and through pathological examination of resected specimens, the depth of infiltration of cancer foci can be confirmed and whether resection is complete. The second category is cancer tissue cauterization and destruction techniques, including argon ion beam coagulation, photodynamic therapy (PDT), endoscopic laser therapy, and local drug injection.
These techniques cannot recover the lesion specimen and cannot determine the completeness of lesion removal. Currently, most scholars believe that the indications for endoscopic esophageal mucosal resection are as follows.
(1) Lesion length less than 3 cm and width less than 1/2 the circumference of the esophagus.
(2) Esophageal mucosal intraepithelial carcinoma (m1 carcinoma), intra-mucosal carcinoma (mm carcinoma) without invasion of the submucosa and without lymph node metastasis.
(3) Esophageal epithelial severe atypical hyperplasia and Barrett’s esophageal mucosa highly glandular epithelial atypical hyperplasia.
2.The application of VATS in the surgical treatment of esophageal cancer
Since 1990s, only a few units in China have explored thoracoscopic esophageal cancer resection surgery. The use of VATS for esophageal cancer resection has the advantages of small trauma and fast recovery, and overcomes the shortcomings of traditional open thoracotomy, such as cutting off the ribs, resulting in the destruction of the integrity of the thorax, and postoperative pain and impaired mobility of the upper limbs. The specific procedures are as follows
① thoracoscopic free esophagus + abdominal median open free stomach → esophagogastric neck anastomosis.
② thoracoscopic free esophagus + laparoscopic free stomach → esophagogastric neck anastomosis.
(iii) laparoscopic free stomach + thoracoscopic free esophagus → intrathoracic esophagogastric anastomosis. The use of gastroesophageal neck anastomosis or right intrathoracic anastomosis can achieve radical surgical treatment of tumors anywhere in the thoracic esophagus. It can achieve the same resection effect as conventional open-heart surgery, and has the advantages of short operation time, small trauma and quick recovery. There is no significant difference in lymph node clearance and postoperative complications compared with conventional surgery.