The incidence of cancer of the oesophagus has dramatically risen over the last three decades for reasons that remain largely unclear. In the industrialised
and Western nations this has been the biggest increase of any solid organ tumour.
The nature of the disease has also changed. Cancers now predominantly develop from glandular tissue at the junction of the lower (distal) oesophagus and
upper stomach (gastroesophageal junction, GOJ), and are referred to as adenocarcinoma . The other type of oesophageal cancer, squamous cell carcinoma (SCC)
is becoming much rarer, and when it occurs tends to form in the upper (proximal) oesophagus. This tumour is often linked to environmental toxins, smoking
and high alcohol intake.
Adenocarcinoma of the oesophagus is not linked with smoking, drinking or environmental pollutants. The only established risk factor is gastroesophageal
reflux disease (GORD), the presence of which significantly increases the chances of developing this malignancy. It appears to predominantly affect white
or Caucasian males (six times more common in men), usually of middle or high income, and worryingly occurring in younger and younger individuals.
Early symptoms are similar to symptoms of reflux disease. Dysphagia (difficulty in swallowing) is often a sadly late feature. Diagnosis is confirmed by
endoscopy and biopsy. The disease is staged (assessed for how advanced it is) by CT scan, PET scan and endoscopic ultrasound (EUS).
Curative surgical resection ( oesophagectomy ) is possible if the disease is localised to the oesophagus and local glands ( lymph nodes ) only.
If the disease has spread to organs or glands well away from the site of the primary tumour, then curative options are not available, and the disease symptoms
have to be palliated and spread controlled using an variety of treatment modalities including chemotherapy, radiotherapy and stents.
Undergoing Surgery (Oesophagectomy)
The aim of surgery is to cure patients with oesophageal cancer. This is done in the following way:
1. Remove the portion of the oesophagus containing the tumour
2. Remove all the lymph nodes associated with the oesophagus and tumour
3. Reconstruct a new oesophagus, usually from the unaffected part of the stomach
Unfortunately, the anatomical location of the oesophagus makes it very difficult to approach surgically. Not only is it located in the very middle of the
body, but it also crosses three different body compartments; the neck, the chest and the abdomen. This makes any operation a very risky undertaking, and
this is why the mortality rate is at least 5%, and morbidity (major complications) is 40-50%.
Oesophagectomy operations which are mainly in used today ( open oesophagectomy), were actually described in the 1930's and 40's and surprisingly very little
has changed surgically in more than half a century. All these operations require very large incisions in the abdomen ( laparotomy ) and the most effective
operations require an additional large chest incision ( thoracotomy ). These wounds cause huge problems in relation to the very significant trauma inflicted
on patients, which is the major factor in the high risks associated with these operations. Improvements in survival after surgery has come mainly from
our advances in critical care support, anaesthesia, antibiotics and so on rather than surgical technique.
Following open surgery, the return to a normal or near normal quality of life can take up to nine months. Many of the problems at this stage still come
from wound pain, and difficulties associated with eating.
Minimally Invasive Oesophagectomy (MIO) provides a means of performing the same (or better) operation using keyhole-sized incisions. This significantly
reduces the trauma of surgery and consequently many of the risks. Magnified views allow a very radical lymph node dissection, and return to a normal quality
of life is in a matter of weeks rather than months.
Note: The text above was taken from the Department of Thoracic and Upper GI Surgery Royal Devon and Exeter NHS Foundation Trust web site.
I attended a meeting for the Oesophageal Patients Association in Exeter on 24 November, 2007, where my own surgeon Mr Richard Berrisford gave a presentation on the MIO operation.
I recorded the presentation and its following questions and answers session. These recordings can be listened to by clicking on the links below.
For clarity, I have also listed here the questions as asked by the audience.
MIO Presentation
MIO Questions and Answers
Questions as asked by the audience
1. Just one tea break?
2. How many hours for the major operation?
3. How do you make a decision between doing the keyhole and the open operation?
4. I had my operation nearly 11 years ago and I'm doing fine!
5. It wasn't particularly ovbious where the tumor was in that operation. Is that common?
6. Where does the stomach finish up after the operation?
7. Is all the oesophagus removed in the operation?
8. You moved the stomach from below the diaphram to above it. Does anything need to be done surgically to the diaphram, or is it as it was before?
9. Would a fat person have a larger stomach than a thinner person?
10. Are you finding that patients are having less reflux with the higher astamosis?
11. Where do you see the future with this technique... is it being developed around the country?
12. Are the majority of tumors contained within the oesophagus wall?
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