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General Surgery
Perspective on Malignant Esophageal Disease (B)
Built from Maingot's Abdominal Operations
What’s inside
7 sections · 62 slides
Overview
- Scope of this commentary
- Four questions the commentary works through
The changing pattern of esophageal cancer
Two cancers, two hemispheres, and one that is climbing fast
- Two cell types of esophageal cancer
- Squamous cell cancer in the East and Middle East
- Squamous cell carcinoma of the esophagus
- Adenocarcinoma in the West
- Adenocarcinoma of the esophagus
- Adenocarcinoma seen at low magnification
- Why the rise is not simply less smoking
- Obesity and gastroesophageal reflux as drivers
- Gastroesophageal reflux
- Body mass index
- Proton pump inhibitors and dysplasia progression
- Omeprazole molecule
- Sequence from reflux to adenocarcinoma
- Barrett's esophagus
- Barrett's esophagus under the microscope
- Endoscopic appearance of a Barrett's segment
The argument over screening for Barrett's esophagus
Too rare a cancer in too large a group — or a missed chance?
- The case against screening
- The case for screening high-risk individuals
- 8–17%
- Comparison with colon polyp screening
- Colon polyp seen at colonoscopy
- Rebuttal to the nothing-can-be-done objection
- Antireflux surgery and regression of Barrett's
- Fundoplication wrap at the lower esophagus
- Detection of abnormal mucosa at endoscopy
- Barriers that still block routine screening
Transhiatal, transthoracic and en bloc resection
How much to take out, and through which door
- The two routes to the esophagus
- Transhiatal resection versus en bloc resection
- Direction of travel in the resection debate
- Entry of minimally invasive esophagectomy
- Open versus keyhole access
- Potential advantages of a minimally invasive approach
- Resistance from established programmes
- The referral dilemma facing most institutions
- Perceptions working against surgery
- “
- Linear accelerator treatment room
- The author's prediction on endoscopic techniques
- The colorectal cancer precedent
Technique, systems and outcomes
Where low mortality actually comes from
- Esophagectomy is about the details
- Institutional system versus individual technique
- Three levers on operative mortality
- Replicating open technique through small incisions
- Feasibility and its costs
Staged esophagectomy and technical refinements
Splitting the operation, changing the position, narrowing the tube
- Rationale for a two-stage operation
- Secondary reasons for splitting the operation
- The author's staged protocol
- Evidence status of staged esophagectomy
- Prone position for the thoracic phase
- Positive-pressure capnothorax
- Practical gains from capnothorax
- Width of the gastric conduit
- Trade-off accepted with a narrow conduit
Where esophageal cancer surgery is heading
Staying relevant in a field that is moving without it
- A field changing on two fronts
- Threats to the relevance of surgery
- The author's closing argument
- Points to carry away
- References
- References (continued)
- Maingot's Abdominal Operations, 12th Edition