Controversies
Angina and coronary angiography
Preoperative angina is common. In the
setting of unstable angina in a patient with an obvious early tumour
angioplasty, stenting and or CABG are options. In the setting of chronic stable
angina preoperative exercise testing and coronary angiography are probably of no
value. Angioplasty and or stenting target lesions has not been shown to reduce
myocardial events, and may actually increase the bleeding complications that are
encountered as a 6 month course of intense anti platelet therapy is usually
prescribed.
Endo oesophageal ultrasound (EOU)
This can provide detailed information
about the T stage of oesophageal cancer, and monitoring the effects of
preoperative chemotherapy. However it is the N and M stage which determines
resectablibity that is poorly assessed by (EOU), these are better assessed by CT
scan.
Preoperative chemotherapy & or
radiotherapy?
Both modalities have been shown to
result in tumour shrinkage in selected cases, however at present preoperative
chemotherapy has been shown in an MRC trial to increase survival when followed
by surgery.
Lung nodule at the same time
If the nodule is calcified it is likely
to be benign. Basically though a primary lung tumour needs to be differentiated
from an oesophageal metastasis. CT scanning will help to eliminate other
nodules. If a lung primary is suspected, N2 lung cancer disease should probably
be eliminated via mediasteinoscopy. Percutaneous biopsy can in certain cases be
helpful to differentiate primary lung from secondary oesophagus. If the nodule
is on the same side as the thoracotomy for the eosphagectomy then a frozen
section can be taken at the same time as the eosphagectomy. If it is an early
lung cancer a lobectomy can be performed. If it is a metastasis management is
highly controversial.
Prophylactic antibiotics
Their use is universally accepted, but
which ones is not. The combination of anaerobic and gram –Ve cover seems
reasonable. Patients with artificial heart valves and native valve pathology
should have the BNF guidelines on antibiotic prophylaxis followed.
Anti-acids
Aspiration is common post
eosphagectomy, especially when a neck anastomosis has been performed.
Prophylactic iv anti acids is common practice though not universal.
Preoperative feeding
This has fallen from grace due to the
earlier presentation of patients. However it is occasionally utilised in grossly
emaciated patients, and in patients who cannot swallow who are undergoing pre
operative chemotherapy.
Cream
Some surgeons give the patient between
50 and 100 mL of full fat cream to help identify the chyle duct, hopefully
reducing the incidence of chylothorax.
Epidural analgesia
A high thoracic epidural provides
excellent pain relief post eosphagectomy. A para vertebral probably remains a
second best option. Controversy exists as to whether the epidural is place in an
awake patient or one that is asleep. Preoperative use of aspirin, warfarin,
heparin (even subcut including LMW heparin), and clopidogrel should be looked
for, as they increases the incidence of a spinal haematoma.
Thoracoscopy and or Laparoscopy
The use of these to eliminate
metastatic disease and for lymph node sampling remains controversial and
limited. A mini laparosocopy or throacotomy prior to the full incision in
dubiously resectable cases probably is better and more thorough. The fingers are
very good at assessing the lesser curve and coeliac lymph nodes that can be very
difficult to examine laparoscopically.
What operation for cancer of the
oesophagus
There is no right answer. It depends on
tumour location, size, previous surgery, and surgeon preference. Generally mid
third tumours get an Ivor Lewis, and lower third tumours get either a left
thoracophrenotomy or an Ivor Lewis.
Conduit of choice
The stomach remains the conduit of
choice for most surgeons, however some prefer the colon.
Where to do anastomosis ?
This partly depends on where the tumour
is. Mid third and upper third tumours will almost certainly have a neck
anastomosis.
Lower third tumours can have an
anastomosis either above or below the aortic arch or in the neck. Above or below
the aortic arch depends on the length of tumour fre oesophagus below the arch. A
neck anastomosis is utilised in lower third tumours if a radical eosphagectomy
is being performed.
Which side of the neck to operate on?
It is generally thought that the side that has had a thoracotomy should be opened, since if the recurrent laryngeal nerve has accidentally been damaged then it is impossible to end up with bilateral injury and hence respiratory obstruction if the ipsilateral neck is opened up.
Feeding jejunostomy
See below
DVT prophylaxis
TED stockings and either unfractionated
or LMW heparin should be utilised in all patients, combined with early
ambulation.
Post operative feeding
The use of post operative TPN or a
feeding jejunostomy is again controversial. It should be pointed out that TPN
and jejunostomy feeding in a routine case that goes smoothly is unnecessary,
however should the patient develop a complication that prevents oral intake a
feeding jejunostomy can be life saving. A feeding tube can be passed with an
gastroscope however post operatively should a feeding tube be necessary.
Essential medications
Most can actually be stopped for the
week that the patients are nil by mouth. Other options include PR administration
and the use of IV or via a feeding jejunostomy. Thyroxine should not be stopped
for more than 5 to 10 days without iv or enteral replacement.
Contrast swallow
Some surgeons perform a contrast
swallow prior to oral intake starting. This exam is timed between 4 and 7 days,
however some to not use it and if the patient is well and the chest x-ray is
clear start the patient on 30mL/hr on day 4 or 5.
Postoperative chemotherapy & or
radiotherapy?