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All you need to know about
ESOPHAGEAL CANCER

1. What is the Esophagus?

The Esophagus or food pipe is the muscular tube that connects the throat with the stomach. It serves as a passage to deliver food and liquids into the stomach. It starts in the neck, passes through the chest and has a short portion in the abdomen, before joining the stomach. It is approximately 25cms in length.

2. What are the types of Esophageal Cancer?

The two types of cancers, which commonly affect the esophagus are squamous cell carcinoma, which usually affects the mid-portion or upper portion of the food pipe, and adenocarcinoma, which affects the lower part of the esophagus.

3. What are the causative agents/risk factors for Esophageal Cancer?

The known agents which predispose to this cancer are tobacco use in any form, including chewed and smoked, alcohol consumption, drinking very hot liquids [like tea] regularly, certain hereditary conditions [Tylosis] and Gastroesophageal reflux disease [GERD] which presents as indigestion and heartburn.

This leads to damage to the lower esophagus, producing a condition called Barrett's esophagus, which increases the risk of cancer by 30 - 125 fold. Read More...
4. What signs and symptoms does a person with Esophageal Cancer present with?

The hallmark symptom is difficulty in swallowing solid food - dysphagia.

It is painless and progressive. Gradually there is difficulty in swallowing semisolids, then liquids and finally saliva. Vomiting occurs if the food pipe is completely blocked. Weight loss occurs due to the inability to take a sufficient amount of calories. Other symptoms include those due to spread to other organs; the windpipe [cough], change of voice [nerves supplying the voice box], breathing difficulty [spread to the lungs], and jaundice [spread to the liver]. Read More...
5. What tests are required for diagnosis?

An Upper Gastrointestinal endoscopy looks at the exact location of the cancer and enables a biopsy to confirm the diagnosis and also allows the passage to be dilated [opened up], to allow feeding.

A bronchoscopy, which involves the passage of a fine tube with a light integrated with a camera, is required in patients with cancer of the upper part of the esophagus, which is in close contact with the airway. A Computerized tomography scan [CT scan] or a PET CT scan is required to look at the site and extent of the disease. It gives information to plan the type of treatment. The extent of the cancer is called the stage of the disease. Routine blood tests, tests to look at heart and lung function are also needed. Read More...
6. What are the treatment options for Esophageal Cancer?

The type of treatment depends on the stage of the cancer. If the cancer is at a very early stage, without spread through the wall and without nodes, surgery is the best option.

If the tumour is large or has spread to the nodes or is in close contact with the windpipe or aorta [major blood vessel of the body], then chemotherapy or chemotherapy with radiation is required to shrink the tumour, following which surgery is performed. In cases where the tumour has spread into the windpipe or to the lungs, bone, or liver, chemotherapy alone is used to reduce or relieve [palliate] symptoms. A procedure called stenting, which is placement of a plastic or metal tube is required when surgery is not an option - this tube is placed endoscopically and allows the patient to eat normally. Read More...
7. What types of operations are performed for Esophageal Cancer?

surgery to remove the esophagus and the involved lymph glands is termed radical esophagectomy.

It involves the removal of either the entire food pipe except for a small portion in the neck or the lower half in case of cancers involving only the lower portion of the esophagus. Following this, the stomach is fashioned into a long tube, which is joined back to the remaining portion of the esophagus. The operation is usually performed through the chest, abdomen, and neck [TransThoracic esophagectomy]; but in some patients, it may be performed through the abdomen and neck [TransHiatal Esophagectomy]. Read More... Esophageal Cancer Treatment
8. What is the role of robotic surgery and laparoscopic techniques for Esophageal Cancer surgery?

Conventionally, esophageal cancers were removed by open surgery.

Open surgery is associated with significant pain, lung infections, increased blood loss, and a slow recovery and return to work. In laparoscopic surgery, tiny incisions are used to allow a lighted camera [endoscope] and special long instruments to access the chest and abdomen, allowing the same operation to be performed with great precision and with magnification. This results in less pain, faster recovery and an earlier return to work and normal activities. Robotic surgery is an advanced form of laparoscopy, using a computer interface to increase further the precision of surgery. The recovery is even faster than with laparoscopy. Read More...
9. How long do I need to stay in hospital and what is the recovery pathway after Esophagectomy?

Typically, you are admitted the evening before surgery. The operation lasts 6 - 7 hours, following which you are monitored in the theatre recovery room.

Subsequently, you are closely observed in the surgical High dependency unit [HDU] for 48 hours, following which if recovery is satisfactory, you would be shifted to your room.
After surgery, you will have tubes to drain fluid from the chest, neck and abdomen at the site of surgery. Feeding is either by a tube passed through the nose into the stomach or by a separate tube placed directly into the intestine, and brought out through the skin [Jejunostomy tube]. For the first 5 days, feeding is only through these tubes, subsequently if the anastomosis [site at which the esophageal remnant is joined to the stomach] has healed well, then clear liquids are started by mouth and slowly progressed to thicker liquids, soft solids [mashed or pureed food] and then to solid food. The drainage tubes are removed when the fluid drained decreases usually by day 4 or 5. In an ideal scenario, discharge is by day 6 or 7 after surgery.
Read More...
10. What complications can occur after Esophagectomy?

Esophagectomy is a major operation and has many complications that can occur during and after surgery.

During surgery the commonest complication is bleeding; but with the use of robotic surgery, with better vision, blood loss is minimal and we rarely need to replace blood. The most common complications are related to lung infections [pneumonia] or inability of the lungs to expand and work normally, anastomotic leak, temporary change of voice [due to stretching of the nerves supplying the voice box]. Read More...
11. Are there any restrictions or life style changes after esophagectomy?

For the first 6 weeks after surgery, the diet should consist of soft low residue food.

This is to prevent food impacting in the neck at the site of anastomosis or in the stomach at the site of exit into the intestine.
Foods, which have high fiber content, and hence to be avoided are all nuts and seeds, chickpeas [Chana/Garbanzo beans], lentils [Dhals - small quantities are permitted], beans, apples, prunes, dates, brown rice, brown bread and chapatis/Rotis. White rice, white bread, biscuits, idli, dosa, yogurt, all forms of meat, seafood and egg, potato, sweet potato, and carrot are permitted.
Since the stomach performs the function of the food pipe in addition to its normal function, its capacity is reduced. Therefore, the quantity of food ingested at each meal has to be reduced - 6 small meals instead of 3 large ones. The last meal of the day should be light and consumed at least one and a half hours before sleep. Additionally, the head end of the bed needs elevation with blocks to prevent intestinal contents and food from coming back up the new food pipe [life long]. A multivitamin supplement is also recommended for life.
Read More...
12. What tests are required after surgery and when do I come for check ups?

You should see the doctor, once every 3 months for the first 2 years, then 6 monthly for another 3 years, then yearly after 5 years.

At each visit, the doctor will examine you in detail and perform a few blood tests to see your general condition. The blood levels of iron, vitamin B12, and folic acid can decrease after this surgery due to the removal of part of the stomach. These levels should be checked once in 6 months. CT scans and endoscopy are required only if symptoms are mandating these tests. Read More...