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Toronto Notes 2019 Thoracic Surgery
• CTchest:pneumomediastinum,pleuraleffusion,pneumothorax,contrastinthechest,and subcutaneous emphysema
• upperGIswallowstudywithwatersolublecontrast
■ if negative then perform with diluted barium: contrast extravasation
Treatment
• supportiveifruptureiscontained
■ NPO, fluid resuscitation, broad-spectrum antibiotics, and possible percutaneous drainage of
mediastinum or pleura • surgical
■ <24hfromperforation
◆ primary closure of a healthy esophagus or resection of diseased esophagus
■ >24 h from perforation or non-viable wound edges
◆ diversion and exclusion followed by delayed reconstruction (i.e. esophagostomy proximally,
close esophagus distally, and gastrostomy/jejunostomy for decompression/feeding)
Complications
• sepsis,abscess,fistula,empyema,mediastinitis,anddeath • post-operativeesophagealleak
• mortality10-50%dependentontimingofdiagnosis
Esophageal Carcinoma
Epidemiology
• M:F=3:1
• onset50-60yrofage
• upper(20-33%),middle(33%),andlower(33-50%) • maintypes
■ most common worldwide: SCC in upper 2/3 of esophagus
■ most common in Western countries: adenocarcinoma in distal 1/3 of esophagus
Risk Factors
• SCC
■ underlying esophageal disease such as strictures, diverticula, and achalasia ■ smoking, alcohol, hot liquids
■ more common in black and Asian populations
• adenocarcinoma
■ Barrett’s esophagus (most important), smoking, obesity (increased reflux), and GERD ■ more common in Caucasian populations
Clinical Features
• progressivedysphagia(mechanical):firstsolidsthenliquids • odynophagiathenconstantpain
• constitutionalsymptoms
• regurgitationandaspiration(aspirationpneumonia)
• hematemesisandanemia
• direct,hematogenous,orlymphaticspread
■ trachea (coughing), recurrent laryngeal nerves (hoarseness, vocal paralysis), aortic, liver, lung, bone, celiac, and mediastinal nodes
Investigations and Staging
• bariumswallow:showsnarrowing–suggestivebutnotdiagnostic
• endoscopic biopsy and assess resectability
• both SCC and adenocarcinoma use TNM staging system but have separate stage groupings according to
histology
• endoscopicU/S(EUS)
■ visualize local disease
■ regional nodal involvement (number of nodes may be more important than location) • bronchoscopy±thoracoscopy
■ rule out airway invasion in tumours of the upper and mid esophagus
• full metastatic workup (CXR, bone scan, CT head, CT chest/abdomen/pelvis, and LFTs, etc.) • PET scan more sensitive than CT in detecting metastatic disease
Treatment
• ifpresentwithdistantmetastaticdisease
■ treat with systemic therapy and treat symptoms (esophageal stent)
• iflocallyadvanced(locallyinvasivediseaseornodaldiseaseonCTorEUS) ■ multimodal therapy
◆ concurrent external beam radiation and chemotherapy (cisplatin and 5-FU)
◆ possibility of curative esophagectomy after chemoradiation if disease responds well
■ if unable to tolerate multimodal therapy or if highly advanced disease, consider palliative resection,
A
A. Median sternotomy
B. Transverse thoracotomy (clam shell)
C. Anterolateral thoracotomy
D. Lateral thoracotomy
E. Thoracoabdominal thoracotomy
F. Posterolateral thoracotomy
Figure 7. Typical thoracic surgery incisions
Perioperative Chemo(radio)therapy vs. Primary Surgery for Resectable Adenocarcinoma of the Stomach, Gastroesophageal Junction, and Lower Esophagus
Cochrane DB Syst Rev 2013;5:CD008107
Study: Review of RCTs to examine the effect of perioperative chemotherapy for gastroesophageal adenocarcinoma on survival and other clinically relevant outcomes.
Results/Conclusions: 14 RCTs, 2,422 participants. 1) Perioperative chemotherapy was associated with
a significantly longer overall survival (HR 0.81, 95% CI 0.73 to 0.89), a relative survival increase of 19% and an absolute increase of 9%.
2) Tumours of the GE junction showed a more pronounced response to perioperative chemotherapy compared to other sites.
3) Combined chemoradiotherapy was more effective for tumours of the esophagus and GE junction compared to chemotherapy alone.
4) Perioperative chemotherapy was more effective in younger patients and is associated with longer disease-free survival, higher rates of R0 resection, and a more favourable tumour stage upon resection.
5) Resection with negative margins is a strong predictor of survival.
General Surgery and Thoracic Surgery GS15
B
C
F D
E
brachytherapy, or endoscopic dilatation/stenting/laser ablation for palliation
© Eddy Xuan 2003