1.Does a patient with dysphagia or dysphagia have esophageal cancer?
In thoracic surgery or gastroenterology clinic, we often encounter some other patients who complain that they always feel a blockage behind their chest when eating,
For several years, the degree of dysphagia or dysphagia was relatively mild, but now it is getting worse. Since the knowledge of cancer is becoming more and more popular, his relatives were afraid that he had cancer, so they came to see the doctor. The thoracic surgeon performed an upper gastrointestinal tract imaging and gastroscopy and told him that he had a tumor in his esophagus, which was a benign tumor called esophageal smooth muscle tumor. It was a benign tumor called esophageal smooth muscle tumor, which needed to be removed surgically because it had grown to 125px in size. What is esophageal smooth muscle tumor? We know that the structure of esophagus is composed of muscles, the inner layer is the circular muscle, and the outer layer is the longitudinal muscle. This kind of tumor in the upper gastrointestinal tract is characterized by limited indentation outside the esophageal mucosa, and the indentation of the upper and lower edges of the lesion is relatively clear and sharp.
The mucosa of the esophagus was found to be normal on fiberoptic gastroscopy, but the mucosa where the tumor was located was protruding into the lumen, and now ultrasound gastroscopy can clearly identify it as a substantial extra-mucosal mass. It should be mentioned that when clinical suspicion of esophageal smooth muscle tumor is present, gastroscopy should not be performed for pathological biopsy, because one cannot take the diseased tissue, and the second bite of mucous membrane will have certain influence on the later surgical removal, and it is easy to occur that the esophageal mucous membrane will break down and cause complications. If the tumor is small and the symptoms are mild, it can be observed regularly and surgery may not be performed immediately. In case the tumor is large, especially if the tumor is lobulated and the esophageal mucosa is embedded in the tumor, the removal of the tumor may damage the esophageal mucosa, and then the mucosa should be repaired properly. The patient’s prognosis is not affected. However, if the esophageal mucosa is damaged during the operation and not noticed or discovered, the postoperative period may result in esophageal pleural fistula, which is more complicated and difficult to deal with such complications, which is a problem that clinical thoracic surgeons should pay attention to.
2.What should I do if I have esophageal cancer?
Esophageal cancer is a malignant tumor of the esophagus, which not only causes clinical symptoms such as choking sensation or difficulty in swallowing when the patient eats, but also directly affects the patient’s nutritional status, and without treatment, the tumor cells can metastasize through the lymphatic system or blood system, which seriously threatens the patient’s life. As we all know, esophagus is a lumen of the digestive tract and its main function is to pass food. When esophageal cancer occurs, the tumor grows to narrow the lumen of esophagus and the passage of food is obstructed, which leads to clinical difficulty in swallowing. This symptom becomes more and more obvious as the size of tumor increases and the lumen of esophagus narrows, and finally it reaches the point that even water cannot be passed. Think about it, a patient has an appetite, wants to eat very much, and can eat, but soon after eating, he spits out completely, and the patient keeps complaining about being hungry, how painful it is! Long-term inability to eat, nutrition is difficult to maintain, the patient is in a state of chronic hunger, the final bone thin as material, without treatment eventually died of starvation. This is unacceptable to both patients and their relatives.
Therefore, once the diagnosis of esophageal cancer is clear, active treatment is needed. The most effective treatment for esophageal cancer depends on the stage of the disease. Clinically, the most effective treatment is surgical resection, in which the diseased esophagus is removed together with the tumor, and the esophagus is replaced by the stomach, small intestine or large intestine to maintain the continuity of the digestive tract, and the patient can resume eating through the mouth after surgery. In China, the most common replacement of the esophagus is the stomach. Depending on the location of the tumor, such as lower esophageal cancer, middle esophageal cancer and upper esophageal cancer, the anastomosis between the stomach and esophagus after surgical resection is below the aortic arch, above the aortic arch and the esophagogastric neck anastomosis, respectively. Some medical centers also use small intestine instead of esophagus and colon instead of esophagus, but the surgery of small intestine and colon instead of esophagus is more complicated and has more comorbidities, so most thoracic surgeons do not use it much, and only use small intestine or colon when it is difficult to replace the esophagus with stomach.
3.What are the comorbidities after esophageal cancer surgery?
Thoracic surgery is one of the larger and more complicated human surgeries, and esophageal cancer surgery is one of the larger thoracic surgeries, which requires general anesthesia, long operation time, much bleeding, and will damage some tissues and organs if the operation is not performed carefully, therefore, the operation of esophageal cancer surgery has certain risks and is only performed in medical units with certain level of thoracic surgery. Even in such a high level medical center, there is still a considerable possibility of complications in esophageal cancer surgery, with a general complication rate of 10% and an operative mortality rate of 3-5%. In the immediate postoperative period, these include asphyxia, active intrathoracic hemorrhage, pulmonary atelectasis, pulmonary infection, anastomotic fistula, respiratory insufficiency, laryngeal nerve injury, incisional infection and gastric emptying disorder. In the distant postoperative period, there may be reflux esophagitis, anastomotic stricture, and dyspepsia.
As with any endotracheal tube surgery, postoperative asphyxia, also known as acute airway obstruction, can occur in patients with esophageal cancer. This situation occurs most often when the patient is not fully awake from anesthesia, spontaneous breathing has not been fully restored, and the endotracheal tube has been removed, especially in those patients with fat body, short stature and short neck, the posterior fall of the tongue root can easily block the larynx and cause acute obstruction of the airway. The best way to prevent respiratory asphyxia is to avoid its occurrence. If the patient is awake, but the strength of spontaneous breathing is still insufficient, an oropharyngeal tube can be placed to prevent the tongue root from falling back, and the patient’s breathing should be observed at all times when escorting the patient out of the operating room. Once the airway is found to be obstructed, artificial respiration should be performed in situ immediately, while emergency endotracheal intubation, ventilator-assisted breathing, if the rescue is urgent, proper measures, the patient’s life can still be saved, otherwise the consequences are unthinkable. I have encountered several cases of asphyxia after general anesthesia surgery, the experience is that the patient did not leave the operating room, most of them can be successfully rescued, but unfortunately, those who were found in the middle of escorting the patient back to the ward from the operating room, or have returned to the ward to find asphyxia, most of them are found too late, or timely detection but lack of effective rescue tools, resulting in prolonged cerebral hypoxia and failure of rescue.
4.Anastomotic fistula is a serious complication after esophageal cancer surgery
The most serious comorbidity after esophageal cancer surgery is anastomotic fistula, the incidence of which was 10% in the past, but once anastomotic fistula occurs, the mortality rate is 50%, that is to say, if anastomotic fistula occurs after esophageal cancer surgery, one of every two patients will die because of fistula. This was the most worrying complication for thoracic surgeons after esophageal cancer surgery in the past. Nowadays, the incidence of anastomotic fistula after esophageal cancer surgery has been significantly reduced due to the improvement of technology, patient’s physical fitness, and the application of anastomosis, etc. Even so, the occurrence of anastomotic fistula cannot be completely avoided in higher level medical centers because of the many factors involved. Currently, the incidence of postoperative anastomotic fistula in China is less than 3%, and the death rate is lower than before. What are the causes of anastomotic fistula? When it comes to the causes of anastomotic fistula, there are several factors at play.
The first is the structure of the esophagus itself. As already described, the blood supply to the esophagus itself is phased, with the upper part being supplied by the inferior thyroid artery, the middle part by the bronchial artery and esophageal artery, and the lower part by the pericardial diaphragmatic artery and the left gastric artery. In addition, the structure of the esophagus lacks a plasma membrane, and its outer wall is covered with a fibrous membrane or epithelium, which is obviously less capable of healing than the plasma membrane. Another factor is the surgical technique, the anastomosis is too deep and the blood flow is destroyed, the distance between stitches is too wide or too close, the knot may be too loose and the anastomosis may be left with a gap, the knot may be too tight and the anastomosis may be cut. Also, inadvertent damage to the stomach wall tissue or local hematoma may occur when the stomach is freed. It is common that most of the esophageal cancer patients have hypoproteinemia due to obstructed feeding and long-term malnutrition, and such patients have weak healing ability, unlike normal people, so it is not difficult to understand that anastomotic fistula occurs.
5.What are the problems that patients with esophageal cancer should pay attention to after surgery?
Part of the esophagus is removed during surgery for esophageal cancer, and the stomach is used to replace the esophagus to restore the continuity of the digestive tract. At this time, the role of the cardia at the beginning of the stomach has completely disappeared, the volume of the stomach is significantly smaller than before, and the position has changed from being located in the abdominal cavity to being located in the thoracic cavity, and from transverse to longitudinal position. All these will cause changes in the body’s digestive function. Therefore, postoperative patients should eat high-calorie, easy-to-digest liquid food or soft rice, and eat less and more meals, with 5-6 meals a day being appropriate. It is not advisable to lie down immediately after the meal to avoid choking and coughing caused by the return of food into the trachea. This kind of diet rule generally should be adhered to six months to a year. Later, the patient can resume three meals a day like normal people, and the total amount of food can reach the pre-operative level. In some patients, there is a feeling of food pause after eating, easy to be full and bloated, and there is a gas string-like feeling in the stomach, so they need to burp as much as possible before eating.
This is what we call “small stomach syndrome”, mainly because the volume of the stomach is reduced after surgery, so the air swallowed has nowhere to stay and can only enter after it has been expelled. In addition, because the vagus nerve was cut during the operation, some patients can have abdominal discharge and saliva increase, which can be treated symptomatically. Some patients have postoperative acid reflux, burning pain behind the sternum, vomiting or even vomiting blood. This is because the anastomosis is too large and the stomach contents can easily reflux into the esophagus. Patients with this symptom should see a doctor for fiberoptic gastroscopy and esophageal manometry and PH measurement to determine the presence of reflux esophagitis and anastomotic ulcers. Conservative treatment is effective for reflux esophagitis, but surgery may be considered in severe cases. Some patients have postoperative dysphagia, the cause of which varies depending on the time of occurrence. Obstruction of feeding that occurs two weeks after surgery is often indicative of a surgical error, such as a narrowing of the esophageal lumen due to mis-sewing of the anterior and posterior esophageal walls. If the obstruction to feeding occurs about two months after surgery, it is usually due to a small anastomosis and postoperative scar contraction, which leads to anastomotic stenosis.
In the case of stenosis due to scar, dilatation therapy is feasible in mild cases, while in severe cases, surgical resection of the stenosed part is required for reanastomosis. If the obstructive symptoms appear after a considerable period of time after surgery, especially if the tumor is not removed from the surgical stump, tumor recurrence should be suspected. This should be confirmed by upper gastrointestinal imaging and pathological biopsy by fiberoptic endoscopy. After tumor recurrence, those who are physically able to tolerate surgery can be considered for re-operation, while those who are not able to undergo surgery can undergo radiotherapy or chemotherapy, or jejunostomy to maintain patient’s nutrition. Even if there are no obvious uncomfortable symptoms, the patient should be followed up regularly in the early postoperative period, usually 1-3 months. If there is no obvious abnormality after several follow-up examinations, the follow-up period can be extended appropriately. In addition to the physical examination, the doctor can do other examinations such as routine blood test, chest X-ray, abdominal “B” ultrasound, upper gastrointestinal tract imaging, and fiberoptic gastroscopy if necessary. If abnormalities are found, corresponding treatment measures should be taken.
6.Can esophageal cancer be treated with radiotherapy?
As we know, esophageal cancer is a malignant tumor occurring in the squamous epithelium of esophageal mucosa, which is a solid tumor and the first choice of treatment is surgery. Therefore, it should be removed surgically if it is available. However, in fact, most of the patients who come to the outpatient clinic are already in the middle and late stage of tumor, and only 1/5 of the patients can achieve the purpose of radical treatment by surgery. After surgery, radiotherapy or chemotherapy is required. Years of clinical experience have shown that esophageal cancer is not very sensitive to current chemotherapy drugs, so the main postoperative adjuvant treatment is radiotherapy. In some cases of esophageal cancer, the tumor is found to have severely invaded the descending aorta or the left main bronchus at the time of surgery, and the tumor cannot be removed, so the surgery has to be aborted and replaced by postoperative radiotherapy. In some cases, the pathological examination of the specimen after surgery reveals the presence of tumor cells at the severed end, which is clinically referred to as positive stump, and such patients also need radiotherapy after surgery. The third type is that the resected specimen shows metastasis in lymph nodes.
The fourth type is patients with clear diagnosis of esophageal cancer, but the patient’s cardiac or pulmonary function is too low to withstand open-heart surgery, or the tumor is known to be too large and invade important organs, so it is estimated that it cannot be removed even after open-heart surgery. All these four cases are indications for radiotherapy for esophageal cancer. Like radiotherapy for lung cancer, radiotherapy for esophageal cancer is also applied with electron linear gas pedal and 60 cobalt long-distance external irradiation, and the dose of common postoperative external irradiation for esophageal cancer is 4000-6000 rad. Radiation therapy can also be used in cases of local lymph node metastasis, for example, if lymph node metastasis in the neck is found after resection of middle esophageal cancer with supra-arch anastomosis, local radiation therapy to the neck can be performed with good effect. Generally speaking, the two sites of postoperative irradiation for esophageal cancer are the mediastinum and the neck, while the lymph nodes in the deep abdominal cavity cannot be reached by radiation. The effect of postoperative radiotherapy is unanimous, and the survival rate of radiotherapy is significantly higher than that without radiotherapy, which is statistically significant.
7.What is preoperative radiotherapy for esophageal cancer?
Because the symptoms of esophageal cancer appear late, when the lumen of esophagus is blocked by tumor for more than 1/2 of the time, the patient shows symptoms of poor feeding or difficulty in swallowing, so the diagnosis is late and the surgical resection is often incomplete or the tumor cannot be removed, and the effect of treatment is obviously reduced. In order to improve the effect of treatment, some doctors suggest whether patients with definite diagnosis of esophageal cancer should undergo a course of radiotherapy before surgery, so as to improve the effect of surgical treatment. The purpose of doing so is to shrink the tumor to facilitate complete removal of the tumor, reduce the scope of surgical resection, preserve as much healthy tissues as possible, reduce the spreading ability of tumor cells, occlude small blood vessels and lymphatic vessels around the tumor, reduce the spreading of tumor cells during surgery, and at the same time, radiotherapy before surgery can kill the tumor cells in the surrounding invaded tissues to reduce the recurrence of tumor after surgery.
Theoretically, preoperative radiotherapy for esophageal cancer has certain benefits, but in practice, there are still many arguments and no unified opinion. Thoracic surgeons believe that preoperative radiotherapy does not increase the difficulty of surgery, but the fibrosis of the esophageal wall reduces the healing ability to a certain extent and increases the possibility of anastomotic fistula. Some medical centers have found no statistically significant difference in long-term survival rates between patients treated with preoperative radiotherapy and those treated without radiotherapy and operated on. This also raises the question, if timely resection of the tumor is well known and no beneficial results are found after a course of radiotherapy, then preoperative radiotherapy is something that can be done or not done, and can preoperative radiotherapy continue? Perhaps there is still some work to be done in preoperative radiotherapy to improve the treatment outcome so that the patient can get more benefit. In recent years, some people have tried radiotherapy during esophagectomy to improve the effect of surgery and radiotherapy together, which is a positive and useful exploration.