esophagus ca. upper third - Forum

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Noro

esophagus ca. upper third - Ärzteforum

Post#1 »

I'll appreciate your opinion about this case :

Female Patient 64 y.o. with background of heavy smoker .
Epidermoid ca. upper third of esophagus ( 4 cm length ).
Apparently (TC and bronchoscopy ) no disease beyond of esophagic wall.
She Just did a pre op. protocol of Rt ( 2000 rads ) and chemo and currently
the lesion persist . Until now we had decided on total esophagectomy with
esophagusgastroplasty
but her spirography date are:
Height : 1.55 mt. -weigh : 48Kg
Vital capacity : measured 2.43 lts ( theoric : 2.31 lt.)
EFV1 :measured 1.92 ( theotetical value :1.92 lts ) VC / EHV1 : 55%
Our dude is the risk of p.o respiratory morbidity .
The questions are :
1.- you would decide operate or send she to complete palliative radiotherapy ?
2.- would rise the stomach by posterior mediastinum ( esophageal lodge ) or behind of
sternum (anterior mediastinum ) ?


User avatar
Surgeon

Re: esophagus ca. upper third - Ärzteforum

Post#2 »

Apparently your patient has disease confined to the oesophagus; surgery is
the only possibility to cure her.
The spirometry data do not seem too bad and are , in fact, what you can
expect in a heavy smoker (most patients with esoph cancer, in our
experience). What we would do in a fragile patient like this is admit her 2
weeks before surgery and start a regimen of parenteral nutrition and
intensive chest physiotherapy. The most appropriate procedure would be, in
my opinion, the Akyama operation. I do not suppose that the position of the
stomach conduit (mediastinal or retrosternal) has much influence on
respiratory complications. Postoperative early enteral feeding (needle
jejunostomy) seems to be beneficial.

Hans

Re: esophagus ca. upper third - Ärzteforum

Post#3 »

I did not notice advantage of early postoperative enteral feeding.

The postoperative enteral feeding in patients with upper GI cancer remains
controversal.

The prospective study randomized 195 patients to early enteral feeding vs
intravenous and demonstrated no reduction in morbidity , mortality, or length of
hospital stay. Routine use in these patients is not recommended.

A prospective, randomized trial of early enteral feeding after resection of
upper gastrointestinal malignancy.

Noro

Re: esophagus ca. upper third - Ärzteforum

Post#4 »

I agree that the use of early enteral
feeding after surgery for esophageal cancer remains controversial. The
Memorial study apparently did not find any benefit; other reports (see
below) do support enteral feeding. Until more data are available, we
like to give enteral feeding the 'benefit of doubt' because of its
relative cheapness, ease of administration and the attractive hypothesis
of protecting gut barrier function in these patients.

User avatar
Billroth

Re: esophagus ca. upper third - Ärzteforum

Post#5 »

There is more than one question to answer here:

First, radiation for epidermoid cancer of the gus is not always paliative.
It offers about 15% chance of 5 year survival, which is much lower than
that of an operation, but if you consider that only the 'Good' patients
are operated, and that irradiation is given to all cases, the actual 5
year survival data may even be better with irradiation. There are no RCT's
as far as I know. If tumor persists after curative irradiation dose,
surgery can still be contemplated.

Second, the spirometry values you give are good, and with such an
FEV1, there is little additional risk for pulmonary complications.

Third, if I were to operate, I would do a total esophagectomy as you
propose. I don't like bringing the stomach up, because of late
complications due to alkaline reflux. I think that the colon is a better
choice, but if there is doubt about the marginal artery (drummonds) I
would bring the stomach through the esophageal bed.

Lastly, the decision to have an operation or complete the irradiation,
should rest with the patient, not the surgeon or the radiotherapist. You
should present the patient with the data and let her decide.

The PATIENT is trading increased morbidity and immediate mortality risk
for a prospective improved chance of long term survival. It is the
patient who should decide if this is a fair exchange. Some patients would
think it is, while others will thing not.

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