Esophagus cancer

Esophageal cancer is 12-15% of malignant neoplasms of various organs, and among the diseases of the esophagus -74% (A. I. Feldman). Cancer P. often affects men (78%); more than 70% of patients older than 50 years, the average age of 60 years. In 6-14% of cases the tumor is found in the cervical and Wernigerode departments, 30-35%- on the level of bifurcation of the trachea and 30-60%in nizhnegorodsky Department and in the field of the cardia. Disease duration from the onset of symptoms to treatment through different. Early treatment of patients (up to 2 months. from the onset of the disease), according to B. C. Petrovsky registered only in 11% of cases, and G. A. Danielyan,- 15%.
Pathological anatomy. There are several pathological classification of esophageal cancer. In clinical practice the most common next (figure 10).

Fig. 10. Different types of esophageal cancer: 1 - skirr, endophytic form; 2 - a simple cancer combined growth; 3 - mozgoviy cancer, exophytic form: 4 - papillary cancer with extensive ulceration; 5 - cancer of the initially benign polyp.

1. Exophytic, or hub, cancer occurs in about 60% of all cases. In the initial stages of tumor development is defined in mucosal and submucosal layer. If ezofagoskopia noticeable pale colored wall section P. tumor Surface grainy, sometimes with point hemorrhages. The mucous membrane is not wounded, but rigida and bad moves. Larger units resemble cauliflower. Sometimes the surface of the tumor ulcerated and bleeds. Hemorrhage occur in the tumor and surrounding mucous membrane. In advanced stages, the host gets a saucer-like form with the collapse and ulceration in the center and high artificial hill-around the edges. Histologically often revealed squamous cell carcinoma. In the future, these tumors become less differentiated structure.
2. Endophytic, or ulcer, cancer accounts for 30% of all cases of cancer of the esophagus. In more equal than stage has the form of a flat knot of white color, which is located in the thickness of the mucous and submucous layer. Site soon ulcerated; the edges of the ulcer eaten, bumpy, uneven bottom, ulcer bleeds easily. In this form early dysphagia occurs because the tumor spreads quickly circular and joins spasm P. Histologically find a picture of squamous cell cancer without keratinization or orogovevshie with the collapse, ulceration and inflammatory infiltration.
3. Sclerosing (circular) form occurs in 10% of cases. Evolving from the mucosa, the tumor grows slowly in a circular direction, there is infiltration of the mucous membrane and muscle membranes esophageal tumor cells. Pitting occurs late in the developing secondary esophagitis.
The germination of mediastinum and metastasis also come late. Microscopically, the tumor has build squamous orogovevshie or basal cell carcinoma with a significant growth of fibrous stroma, there is a picture of Skira.
Cancer of the cardia, usually adenocarcinoma, grows from the bottom up, spreading into the submucosal layer.
The structure of cancer P. not always possible to attribute it to any clearly defined form. Meet mixed forms with ekzotichna-endophytic tumor growth.
In the metastasis of tumor has its own laws. Cancer cervical esophagus early spreads in fiber spaces of the neck, supraclavicular areas and mediastinum. Tumors of thoracic give metastases in lymph nodes in the mediastinum and okoloplodna fiber. Verkhovskii metastases in the left supraclavicular region is characteristic for running all cancer of the esophagus. For cancer of the middle and lower thoracic typical are metastases in the lymph nodes lesser omentum. The liver is affected by metastases approximately 20% of cases, light - 10%, other abdominal organs and bone less often.
Clinical course. Symptoms of P. at different stages of its development is very diverse. They can be divided into three groups: 1) General symptoms that are found in various chronic diseases and lesions of cancer, including cancer P.; 2) the symptoms of the disease of the thoracic cavity (dull pain in the chest or back pain, shortness of breath, growing by the end of the meal, tachycardia after eating, changing the tone of voice and other); 3) immediate symptoms lesions of the esophagus.
The third group of symptoms, the most important in the diagnosis of cancer P. includes dysphagia, increased salivation, pain when swallowing, especially solid food, a sense of "scratching" the sternum, bad breath and bad taste, nausea, belching. One of the early symptoms of cancer of the esophagus - dysphagia (found in 80% of cases) the first is not always clear and appears periodically. Exophytic tumors it is often the first symptom that occurs on the background of General well-being. There are three types of dysphagia: functional reflex (usually earlier), mechanical (symptom developed or released cancer), mixed (mechanical narrowing of the lumen and reflex spasm of the muscles). The General condition of cancer patients P. gradually getting worse, especially with the increasing dysphagia. Progress exhaustion and dehydration. Complications (bleeding, esophageal-tracheal and esophageal-bronchial fistulas, perforation tumors in the mediastinum, the pleura, pericardium, lungs) lead to the development of anemia, lung abscess, mediastinitis, purulent pericarditis, empiema pleura.
The diagnosis is made on the basis of the above symptoms. However, a number of "poor-water" signs typical of other diseases of the esophagus, so the differential diagnosis must be aware of: kardiospazm, benign tumors, ulcers, tuberculosis, syphilis, actinomycosis, stricture P. on the grounds of relucateroca hernia hiatal, diverticula. On the basis of the clinical picture, especially in the initial stages of the disease, install only a presumptive diagnosis that specify radiographically. The diagnosis of esophageal cancer is a clinical-roentgenological. When confusion after the x-ray is required endoscopy with biopsy.
Surgical treatment. There are radical and palliative surgery. When radical operations performed resection of cancer P. with simultaneous restoration of patency of his or subsequent creation of artificial P. Palliative operations provide power when the patient undeleted tumors. Contraindications to radical surgery are: large tumors that spread to nearby vital organs, the presence of distant metastases, severe diseases of the cardiovascular system, the lungs, parenchymatous organs, old age and other
Given that the vast majority of operations on the esophagus perform transpleural, preparation for operation is essential. To improve patency P. apply antispastic funds (0.1 % solution of atropine 5 to 7 drops or herb infusion for 7 drops 3 times a day for 15-20 minutes before a meal), vegetable oil 1/2-1 teaspoon before each meal. In cancer of the esophagus are observed serious violations of water-salt, fat, and protein metabolism. Therefore, the diet should be high in calories, containing a sufficient amount of proteins, fats, carbohydrates, vitamins, but gentle. If dehydration - daily intravenous and subcutaneous infusion (2,5-3 years) 5% glucose solution, sodium chloride (0.9% solution), potassium chloride 0.3% solution). Enter protein preparations (plasma protein blood substitutes), stimulating blood donations (200-250 ml). When heart disorder appoint strychnine, strofantin, digitalis and other
Currently, the vast majority of surgeons operates under endotracheal anesthesia with the use of muscle relaxants. The method of anesthesia is the same as with any transpleural intervention. The use of hypotensive drugs (arfonad, pentamin)providing managed hypotension, causes less bleeding; they are necessary and to prevent shock.
Surgical access to the esophagus depends on the tumor location. When tumors located in the cervical part of the Isthmus, apply oblique cut on the leading edge of the left sternoclavicular-liners muscle tumors located at the level of the thoracic P.,- transpleural approach. When a tumor is located in Wernigerode Department and at the level of bifurcation of the trachea use right anterior-lateral incision in the V or VI intercostal space, which allows after crossing v. azygos to open the mediastinum throughout and highlight the esophagus together with the tumor.
When a tumor is located in nizhnegorodsky Department P. the most rational is left transpleural access in VI or VII intercostal space with the crossing of a costal arch. In cancer of the cardia and abdominal P. use transabdominal access. Oligomerov perform median laparotomy, and brachiolarian prefer slash cut parallel to the left costal arch crossing the left and partially right of recti. With the spread of tumors to the level of the diaphragm produce the sagittal diafragmei by A. G. Savinykh. In some cases, using combined access: start with laparotomy and finish the operation transpleural intervention.
Resection of the cervical esophagus begin patchwork incision in the neck (figure 11). The left lobe of thyroid gland, assign to the medial side. P. mobilize together with the tumor and surrounding lymph nodes. After resection P. in healthy tissues pharyngeal and distal sewn into a skin wound (Fig. 12). After 1 to 2 months. produce plastic skin (Fig. 13). This method of plasty of the Isthmus is not always possible, so it is better to apply transplant stalked flap Filatov.
Surgery for cancer of the upper part of the breast section of the esophagus produce as in cancer, located near the bifurcation. While the most widely operation Dobromyslova - Torca and resection of the esophagus with simultaneous imposition of esophagogastrectomy on Garlake.

Fig. 11 - 13. Resection of the cervical esophagus: Fig. 11 - patchwork incision in the neck; Fig. 12 - pharyngeal and distal esophagus filed to the skin; Fig. 13 - stitching mobilized the edges of the skin on top of the skin of the tube.

When the operation Dobromyslova - Torca after opening the pleural cavity conduct an audit of the mediastinum. Mediastinal the pleura cut, allocate the lower esophageal tumors fingers and surround gauze strip. Cross the azygos vein, cut through the mediastinal pleura up to the dome of the pleura and P. separated from the mediastinum above tumors (Fig. 14). Select the esophagus of the mediastinum easier after the infiltration of 0.25% solution novokaina, which detaches the left leaf mediastinal pleura and prevents the occurrence of bilateral pneumothorax. Mobilized P. cross at the cardia, aboral end immersed in a purse string suture, and oral put on the rubber cap (Fig. 15). Having laid the sick in the back, through a small incision in the right supraclavicular region allocated cervical P. the Index finger of the right hand surgeon makes a tunnel and retrieves the esophagus into the wound supraclavicular region (Fig. 16). Level II-III ribs an incision of the skin, creating a small subcutaneous tunnel, which carried out a stump P. (after clipping the most part, P. together with a tumor), and edge P. hem knotted silk sutures to the skin. The surgery is completed gastrostomy on Vitaly (Fig. 17). After 3-4 months. after the operation Dobromyslova - Torca, perform plastic P. - often anatomically plastic from subtle (Ru - Herzen-Yudin) or from the colon. Anatomically plastic is the least dangerous operation for weakened patients undergoing hysterectomy thoracic P., so retrosternal artificial esophagus, vnutriplevralno P. and other plastic surgery performed rarely.

Fig. 14-17. Operation Dobromyslova - Torca: Fig. 14 - the esophagus allocated from the mediastinum and taken into the gauze strips; Fig. 15 - Gypsy Vienna tied up and crossed the esophagus is also traversed by oral end of wearing rubber cap, aboral end immersed in a purse string suture; Fig. 16 - the allocation of the esophagus in the neck; Fig. 17 - the wound of the chest cavity protection. Level II ribs formed esophageal stoma. Imposed a gastrostomy tube.


Resection of thoracic esophageal with the imposition of esophagogastrectomy (operation Garlake). Left-side anterolateral access in the sixth intercostal space open pleural cavity below the tumor cut through the mediastinal pleura, mobilize the esophagus and is surrounded by a gauze strip. Then cut the pleura above the aortic arch and also mobilise the esophagus (Fig. 18). After the mobilization P. together with a tumor cut through the aperture and mobilize the stomach. P. cross over kardia, tie aboral end and immersed in the stomach purse string suture, impose additional knotted serous-muscular silk sutures. Oral end P. tied up and seal with a rubber cap. Then with the tumor P. display above the aortic arch, repetiruyut in healthy tissues and impose esophagogastrectomy (Fig. 19). The stomach is fixed to the chest wall, the corners of the aperture hem knotted silk sutures to the stomach and sew up the hole in the diaphragm (Fig. 20). The surgery is completed the closure of the pleural cavity, leaving permanent rubber drainage in the VIII-IX intercostal space.
In cancer of the lower thoracic esophagus pleural cavity open left-side anterolateral access in the VII-th intercostal space with the crossing of a costal arch. After crossing pulmonary communication open the mediastinum, allocate P., surround gauze strip. Then cut through the aperture. Stomach mobilize together with a large gland, crossing gastrocolic ligament in the transverse colon. Cross are ligated and left gastric artery located in the thickness of the gastro-pancreatic ligament (Fig. 21). After that mobilize cardio and allocate epimenidou part P. together with tumor (Fig. 22). Perineurally impose 0.5% solution novokaina in wandering nerves and cross them. On the stomach in an oblique direction, impose two clamping Pira, between which the stomach is cut and stump tightly sewn double row ketotofin seam (Fig. 22, bottom right). On the front wall of the stomach cut oval hole. The esophagus with tumor repetiruyut and impose esophagogastrectomy (Fig. 19-20).
Now apply the operation resection P. with one-stage plastic segment thin (Fig. 23) or colon (Fig. 24) ulcers in vascular pedicle. But these complex surgical intervention are high mortality and is associated with greater risk.

Fig. 18 - 20. Resection of thoracic esophageal with the imposition of esophagogastrectomy: figure 18-mediastinal pleura cut above the aortic arch and the esophagus allocated from the mediastinum; Fig. 19 - the imposition of esophagogastrectomy; Fig. 20 - esophagogastrectomy finished, the edge of the diaphragm is fixed to the lower part of stomach.
Fig. 21. The intersection of the left gastric artery in the thickness of the gastro-pancreatic ligaments.
Fig. 22. The esophagus is allocated together with the tumor. At the bottom right - overlapping seams on the stump of a stomach.
Fig. 23. Esophagoplasty segment of the small intestine on a vascular pedicle.
Fig. 24. Esophagoplasty segment of the colon on a vascular pedicle.

 

Palliative operations have the aim to provide food; these include: gastrostomy, applying bypass anastomosis, recanalization of the esophagus plastic tubes, diafragmalnaya and vagotomy. In practice, the largest spread recanalization P., which can be made during operation, and also through esophagoscopy using special guides. Of different types gastrostomy (see) is most common method of Vitale.
Complications during and after operations on the esophagus: bilateral pneumothorax, chylothorax, shock, respiratory failure, failure of welds esophago-gastric bypass, bleeding, pneumonia and other
Postoperative mortality, according to domestic and foreign authors, is 30-40%. Remote results of surgical treatment of cancer P.
these are: after radical operation in the clinic B. C. Petrovsky more than 5 years 30% of patients in the clinic B. A. Petrov - 10%, B. S. Rozanova - 11,7%, Nakayama (K. Nakayama)- 4-8%.
Medical treatment with inoperable tumors of the esophagus. Appoint antispasmodic (herb infusion - 5-7 drops before a meal, atropine, papaverina)and neurologiske funds (chlorpromazine, pipolfen and others). Good anti-inflammatory action has potassium iodide (Sol. Kalii iodati 5%) table spoon 3 times a day with milk after a meal.