Treatments by diagnosis
Treatment is entirely dependent on stage, all stage 0 to III undergo surgery, the question being should they have preoperative chemotherapy after the results of the MRC trial. Patients with stage IV disease have to undergo palliative procedures.
Palliative Procedures
Palliation is appropriate when patients are too malnourished or debilitated to undergo surgery, have a tumour that is unresectable due to extensive invasion of vital structures, recurrence of resected or irradiated tumour, and/or due to metastases. Most of these patients have a complete or partial obstruction of the oesophagus due to the tumour and swallowing is very painful or impossible. The goal of palliation is to use the least invasive means possible, limit hospitalisation and relieve discomfort.
Dependent upon the life expectancy, relief is carried out by:External Beam Radiation
Intracavitary Radiation
Laser Therapy
Photodynamic Therapy
Stents
Mainstay is medical management, due to the fact that it is rarely life threatening, surgery is not 100 % effective, and their is a definite morbidity and mortality with any surgical procedure.
Indications for operation
High Threshold
Failure of maximal medical therapy for at least 6 months
Low Threshold
Complications
Peptic stricture
Ulcerative oesophagitis
Recurrent aspiration and pneumonia
Barrett's oesopahgus
Principles of surgery
Create an intra abdominal part to the oesophagus
Add an anti reflux mechanism eg fundopliction
Prevention of the OG junction entering the thoracic cavity
Operative approaches
1 Route
Abdominal - suited for laparoscopic Nissen
Thoracic - suited for Belsey and Collis
Thoracoabdominal - suited for re operative surgery
2 Fundoplication
360 Degree - Nissen
270 Degree - Belsey
180 Degree anterior wrap - Dor
3 Oesophageal lengthening
4 Closure of the Crura
Choice of anti reflux procedure
If uncomplicated the Laparoscopic Nissen is preferred
If poor oesophageal motility as assessed by manometry a partial wrap is preferred eg Belsey
If oesophageal shortening with good motility a Collis combined with a Nissen is preferred, with poor motility a Collis with a Belsey is preferred
Specific Complications
Dysphagia
Gas Bloat syndrome
Slipped repair
Herniation
Gastric or oesophageal perforation
Failure
The most important step in dealing with benign oesophageal strictures is reassuring your self that they are really benign and that no underlying malignancy exists. Hence endoscopy and biopsy is central to their management. All strictures are treated conservatively with repeat dilation, with surgery (usually eosphagectomy) reserved for failure of repeated dilation or perforation after dilatation. Numerous different dilators are available, however the use of a guide wire that is passed through the stricture under direct vision of the scope followed by dilators passed over it with endoscopic checking after dilatation is probably the safest.
The eosphagectomy obviously does not need to be radical as malignancy is not present.
Upper third strictures can be very complicated but can be treated by an interposition graft eg jejunum or via eosphagectomy with a neck anastomosis, Ivor-Lewis or a Left Thoracophrenotomy
Mid third strictures can be treated via an Ivor-Lewis or a Left Thoracophrenotomy. As tumour is not present a left sided approach is fine even though the pathology is behind the aorta.
Lower third strictures can be treated via an Ivor-Lewis or a Left Thoracophrenotomy
Stenting tends to play no role as this is a chronic condition with a long history and stents tend to only work well in the short term. In the presence of a fistula though a covered stent can be invaluable.