Oesophageal Cancer

WRITTEN BY MR T C B DEHN MS FRCS
CONSULTANT LAPAROSCOPIC AND UPPER GI SURGEON

For anyone, receiving news of the diagnosis of cancer comes as a shock. This leaflet is written for you, to explain the clinical problem of oesophageal cancer to you and how you may be investigated and treated. If anything in this leaflet is not clear, do not be afraid to ask any of the Upper Gastro Intestinal (UGI) Specialist team caring for you. Our names and telephone numbers are on the back of this leaflet: we are here to help.

A cancer arises because the cells which line the upper intestine multiply out of the normal control mechanism of the body: in the oesophagus this process usually causes an obstruction to the passage of food resulting in symptoms of food sticking on the way down. In addition, there may be a notable loss of weight. Sometimes a cancerous growth can bleed; this may result in you becoming short of blood (anaemic), or you may vomit blood. If the growth arises in the stomach, vomiting may result from blockage of the exit of the stomach.

In general, the main treatment of oesophageal and stomach cancer is by surgery. These are usually major operations. The operation for oesophageal cancer may involve not only opening the abdominal wall but also opening the chest wall to gain access to the oesophagus.

Staging Investigations
Any cancerous growth, in whatever organ may spread to other organs such as the liver or lungs. This is called secondary spread. Surgery is not usually recommended if secondary spread has occurred and some other form of treatment is offered. In order to minimise the possibility of undergoing surgery in these circumstances, you will undergo several investigations to ascertain whether any spread has occurred. These are called staging investigations: They are not individually 100% accurate, but when all are completed, the accuracy of diagnosing the presence of secondary spread is around 90%.

Not all patients will have all or any staging investigations. Some patients will decide they do not wish to undergo surgery, whilst others may have other medical problems such or heart or chest disease which would make surgery and anaesthesia too risky. If secondary spread is picked up on the initial staging investigation, you will not undergo further staging tests: a variety of non-surgical methods of treatment will then be discussed with you.

Types of Staging Investigations

1 CT Scan (body scan).
This test is an X-ray. You will lie in something akin to a large torpedo tube and the machine takes x-ray 'slices' of your chest and abdomen. If this is normal you may proceed to:

2 Endoluminal Ultrasound (EUS).
This is like the gastroscopy you will have already undergone. It is performed under intravenous sedation and a special endoscope measures the thickness of 'the growth'. It also makes an assessment of the state of the local glands (lymph glands).

3 Laparoscopy
This is carried out under a general anaesthetic. Some patients can go home the same day, others may need to stay in overnight. Between one and five small incisions are made on your abdominal wall and a camera is used to inspect the inner surface of the abdominal cavity: if necessary samples of fluid or tissue may be taken from within the abdominal cavity.

Next stage
If all the staging investigations are normal and you wish to have surgical treatment, your doctors may advise you to undergo some anti-cancer drug treatment prior to surgery. This is known as pre-operative chemotherapy. A recent trial organised by the United Kingdom Medical Research Council has shown a distinct advantage if patients received chemotherapy before surgery. The pros and cons of this treatment will be discussed with you since not all patients are suitable for pre-operative chemotherapy. Some may proceed directly to surgery following successful staging investigations. Chemotherapy treatment is usually given as a combination of intravenous and oral drugs and each cycle is usually of five days of treatment followed by three weeks 'rest'. There is usually a three to five week rest period following the second cycle to allow the body to recover sufficiently before surgery is undertaken.

Thus, the whole process, from diagnosis through staging and pre-operative chemotherapy may take two to three months. Although this may seem a long time, it is vital for your treatment that proper staging is undertaken to prevent unnecessary surgery.

Patients often ask if the cancer will grow during this period: almost certainly it will continue to be present whilst staging is carried out, but chemotherapy may make the cancer shrink and may kill small secondary elements, too small to be diagnosed by the staging investigations.

Nutrition
During the period of pre-operative treatment, it is important that you maintain a high-protein and high-calorie dietary intake. If swallowing solid food is difficult, you will be given advice on how best to achieve this. There are many liquid high-energy drinks available. If, maintaining suitable nutrition becomes very difficult, your doctors may give you supplementary feeds through a very fine bore tube placed in your stomach. This may require a small operation.

Surgical Treatment for Oesophago-Gastric Cancer
The aim of surgery is to remove the cancerous growth and adjacent tissue to which the cancer may have spread including local lymph glands. There are a variety of surgical procedures which your surgeon may use and he will discuss the best approach with you.

In principle, a fairly long piece of the oesophagus has to be removed and the stomach is brought up to be joined on to the remaining oesophagus. This usually requires an incision into the abdominal wall in order to mobilise the stomach from its attachments. Sometimes the chest wall has to be opened.

Other approaches enable the oesophagus to be removed without opening the chest. For these operations an incision is made into the left side of the neck and the stomach can be brought all the way up to be joined to the oesophagus in the neck.

Some surgeons are now able to use keyhole surgery to perform all or part of this operation, but this is very much dependent on the size and location of the tumour and the personal preference of your surgeon.

Immediately after surgery, you will be cared for on the intensive care or high dependency unit of your hospital. You may be on a breathing machine (ventilator) for a short period of time in order to rest your lungs. There may be several tubes attached to your body. Usually one or two tubes drain fluid from your chest. There will be a tube draining urine from your bladder and a tube placed into your intestine in order to give you supplemental feeding. You will be given fluid intravenously and stomach contents will be drained by a naso-gastric tube (a small tube that passes through your nose into your stomach).

Post - Operative Recovery
By and large, nothing very much happens for the first five days and once you are able to breath without the ventilator, you will be sent back to the general ward. During this period some of the chest drain tubes may be removed from you and after approximately a week you will undergo a barium swallow x-ray examination. This will show the integrity of the internal plumbing and, if the join is watertight, you will be allowed to take fluids and food by mouth.

After your operation, the time spent in the ward will certainly not be like a holiday on the beach! Hospitals are busy places and you will be seen by a large number of people. Your surgeon and his team will see you every day and you will be seen by a dietician to help you with your nutrition, a physiotherapist to encourage you to breathe properly and to help you move your legs to increase the flow of blood. Nurses will come round regularly to take recordings of your temperature and drains, to change your dressings and to administer medication.

In the majority of hospitals undertaking this kind of surgery, post-operative pain relief is very efficient and is usually given by an epidural anaesthetic. Sometimes an epidural anaesthetic is not feasible and you may be given painkilling drugs intravenously. Often you can control the amount of these drugs that you receive by a mechanism known as 'Patient Control Analgesia'. In this method, you wear a little wrist watch and press a button every time you feel some discomfort - a small amount of painkilling medicine is injected into you at each button press.

Following completion of the operation, the piece of intestine which the surgeon has removed will be sent off for analysis by the pathology department. Results of this usually take seven or ten days to be returned to the surgeon and he will discuss with you the results and any implications for any further treatment.

We hope you have found the above information useful. Please remember, that this may not be the exact protocol followed in your own hospital and there will be variations on the above theme.

Consent for oesophago-gastrectomy
Having read the attached information leaflet you may feel more able to sign the informed consent document.

All operations, however minor, are subject to an element of risk. Surgery and anaesthesia are a lot safer now than twenty years ago, but not all operations go according to plan. It is important that you understand and are aware of these risks.

The following are a list of the principal complications associated with this type of surgery:
1 Chest infection
2 Clots forming in the legs and travelling to the lungs (deep venous thrombosis and pulmonary embolism)
3 A leak at the join of intestine. This may require a lengthy period of treatment including supplementary nutrition and tube drainage of any intestinal contents. Occasionally, further surgery is needed to secure the leak.
4 A chyle leak - a fine tube carries fat from the intestines into your chest. Sometimes this fine tube is injured inadvertently since it runs in close proximation to the operation site. Usually, this will require further surgery to tie off the tube.

5 Hoarse voice - the nerves that supply the voice box run in close proximation to the oesophagus and may be bruised or inadvertently divided. This usually results in a hoarse voice - in the majority of incidences it recovers on its own after a few months. Sometimes, the injury may leave you with a permanent hoarse voice. This can be corrected by injecting the vocal cord.
6 Removal of the spleen. Sometimes this is necessary since it may get injured during the mobilisation of the stomach. If this does occur, you will need to take penicillin tablets daily.
7.Post-operative mortality. This is a very major operation with the attendant risks. The in-hospital mortality in the United Kingdom is approximately 10%. Our current in hospital mortality is less than 3%.

Because of the magnitude of the surgery, the seniority of many patients suffering from this disease and the presence of cancer, a few patients will, unfortunately, die of complications of surgery. The United Kingdom mortality rate for this operation is around 10%. Many centres are now reporting much lower mortality rates. As with any treatment for cancer, the risks of the treatment must be weighed up against the risks of not having the treatment and continuing with the disease.

Outcome of surgery >>