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S3 Productions Presents
CANCER ESOPHAGUS
Ms Sujata DesaiMs Sarita KumariMs Shiney Sam
• Ms Sujata Desai• Anatomy Physiology• Definition • Epidemiology and incidence• Etiology• Prevention and Screening• Pathophysiology• Clinical Manifestations• investigations• TNM staging
• Ms Sarita Kumari• Classification• Spread• Treatment :- • Surgery
• Chemotherapy• Radiation therapy• Palliative management• Complications
• Ms Shiney Sam• Pre operative management • Post operative management• Rehabilitation• Prognosis• Discharge planning• Follow up
Contents
Ms Sujata Desai
ANATOMY AND
PHYSIOLOGY
Structure• 4 layers Mucosa
Submucosa
Muscularis propria
Adventitia
Functions
Blood Supply and
Nerve Supply
Blood supply
Venous Drainage
Nerve Supply
Lymphatic drainage
Cancer Esophagus
Definition
Country Incidence LinkUS 6 cases/100,000 men/year (Black>white).
China (HenanProvince) 0.9% in the population older than 30 years of age
Nitrosamine in the soil and contamination of foods by fungi (Geotrichum candidum) and yeast, which produce mutagens
India, Pakistan, and Sri Lanka 9000 cases/year in 6 cancer registry
Chewing tobacco , smoking
Singapore Hot beverages, Chinese tobacco and wine
South African Bantus and Zulus Nitrosamine in the soil and contamination of food by molds, especially the Fusarium species
Normandy, Brittany Alcohol and smoking
Epidemiology
Incidence Squamous Adeno
New cases per year 16980 12450Male-to-female ratio 3:1 7:1Black-to-white ratio 6:1 1:4Most common locations middle distalMajor risk factors smoking Barrett’s
alcohol esophagusIn TMH 1200 pts /year2nd most common in men4th most common in femaleM0re than 180 Sx /yr
Etiology• Unknown• Hereditary & Genetics• Smoking and alcohol
• Dietary factors • *N-nitroso compounds (animal
carcinogens) *Pickled vegetables and other food-products *Toxin-producing fungi *Betel nut chewing *Ingestion of very hot foods and beverages (such as tea)
• Obesity• Work place exposure
ACHALASIA
Barrett’s Esophagus
Hiatus Hernia
Plummer Vinson Syndrome
EsophagitisAnemiadysphagia
Tylosis
Esophageal Web
• Helicobacter pylori• Injury : ingestion
of acids or alkalines
• Colic Disease• Chronic peptic
sore• Oral sepsis
• Syphilis• Radiation Therapy• h/o cancer• HPV• Aspirin • NSAIDS
Others
Prevention and screening
• Counseling : Avoid alcohol and tobacco• Endemic mass screening programmes• Screening high risk factor • Surveillance Programme
Barrett’s esophagus without dysplasiaendoscopy 3 yearly
Low grade Dysplasia: every yearHigh Grade Dysplasia every 6months
4 quadrant biopsy 2cm apart
PathophysiologyP53 gene located on chromosome 17p produce nuclear
phosphoprotein
Important for cell
growth & control the cell cycle
progression and
regulate the DNA repair
Mutation or
deletion of p53 genes
Alter p 53 activity
Disturb cell cycle control
Early esophageal cancer
Histologic changes
Clinical manifestation
• Dysphagia• Odynophagia• Hoarseness of voice• Dysphonia• Central chest pain
• Wt loss• TEF• Chronic cough • haemoptysis• Malena or haematemesis• Nausea vomiting, regurgitation• Superior vena cava syndrome
• Bone pain• Malignant ascites• Malignant pleural effusion• Jaundice• Supraclavicular and cervical
lymphadenopathy• Diaphragmatic paralysis
Signs of Metastasis
Investigations
• History and physical examination• Blood examinations: – CBC,LFT, RFT, Electrolytes
• Tumor marker:Alkaline Phosphatase (20 to 140 IU/L)CEA (0 – 2.5ng/ml)
• Imaging Tests– Chest X ray – CT scan– CT guided needle biopsy–MRI– PET scan
• Barium Swallow
Esophagoscopy
• Endoscopy– Upper endoscopy– Endoscopic ultra sound– Bronchoscopy– Thoracoscopy and laparoscopy
•OTHERS
• Biopsy •HER2 Testing
TNM Staging
Staging
Ms Sarita Kumari
morphological
Type I : polypoid
Type ll: ulcerated
Type lll: infiltrating ulcerated
Type lV :diffuse
Classification
Squamous cell carcinomaa) Upper thirds of esophagus-20%b) Middle thirds of esophagus-50%c) Lower thirds of esophagus-30%
Adenocarcinoma
Spread• Commonly spread by Lymphatic system
(1) Local spread Trachea tracheoesophageal fistula Aorta Fatal hemorrhage Recurrent laryngeal nerve hoarseness of voice
• (2) Lymphatic spread *Extensive submucosal lymphatic spread ( proximal
line of resection should be 10cm proximal to the tumour).
*Cervical ,mediastinal and coeliac LNs.
• (3) Blood spread Lung, liver & brain.
• Surgery• Chemotherapy• Radiation therapy• Combination therapy• Palliative therapy
Treatment modality
Management protocol
• 1877- Czerny first surgeon to successfully resect a cervical esophageal cancer
• Initially the anastomosis was done by bringing out the ends subcutaneously with external plastic tubes, skin tubes and flaps
• 1933- Ohsawa first stomach reconstruction
• 1946- Ivor Lewis two staged approach (rt thoracotomy and separate laparotomy)
• 1976- Mc Keown 3 stage operation
• 1982 & 1994 vagus nerve preservation
• 1997 – laparoscopic total esophagectomy
Surgery
Management of early cancers
• Photodynamic Therapy (PDT)
• Drug used: sodium porfirmer
• Neodymium-:yttrium-aluminium-garnet(Nd:YAG)
Laser Ablation
Endoscopic Mucosal Resection(EMR)
After resection protonPump inhibitors are used
Radiofrequency AblationEndoscopic balloon ablative device , kills cells by heating by electric current
Surgery
1) Tumors below the carina (tracheal bifurcation) Ivor Lewis operation
(2 phases ) 1st phase :laparotomy & mobilization of stomach. 2nd phase Rt thoracotomy through the 5th intercostal space resection of the tumor .LNs and 10cm of the oesophagus above the tumor & GE anastomosis.
Operable tumors
Mc Keown operation (3 phases ) 1st phase :laparotomy & mobilization of stomach 2nd phase Rt thoracotomy through the 5th intercostal space :esophageal mobilization 3rd phase: neck incision : the oesophagus & stomach are delivered to the neck where resection is done and anastomosis of the stomach & cervical oesophagus is carried out.
Tumors above the carina
Transthoracic Esophagectomy
VATS
• lt thracoabdominal incision: the stomach & lower oesophagus are removed with
• Roux-en-Y esophagojujenostomy
• .
3) Tumors below the diaphragm (1 phase)
• Other options Transhiatal esophagectomy Thoracotomy is avoided by mobilizing the oesophagus from the abdomen via the diaphragmatic hiatus and via the neck incision
• Field I: abdominal field• Field II: Paraesophageal,
parabronchial, apical nodes, recurrent nodes, paratracheal
• Field III: Cervical paraesophageal, supraclavicular
3 field lymph node dissection
• Endopscopic removal through laparoscopy & thoracoscopy
Reconstructions
Colonic transposition
• Neoadjuvant• Two 4-day cycles,• 3 weeks apart • Cisplatin 80 mg/m2 by infusion over 4 h • fluorouracil 1000 mg/m2 daily by
continuous infusion for 4 days. (MRC protocol)
• Surgery performed two to four weeks after chemotherapy
Chemotherapy
EBRT alone 64.8Gy / 33 - 36 fractionsExternal beam radiotherapy and brachytherapy EBRT• Dose : 60 Gy / 28 fractions with reducing
fields.ILRT Boost : 5 - 8Gy / 2-3 fractions (HDR), one week apart or single fraction 20Gy low dose rate (LDR).
Radiation therapy
Brachytherapy
• 50Gy / 25 fractions over 5 weeks, • Cisplatin 75 mg/m2IV Day 1 of weeks
1, 5, 8, and 11,• Fluorouracil, 1g/m2 per day by
continuous infusion day1 – day 4 week 1, 5, 8, and 11. (RTOG
regimen)
Concomitant chemo radiation
• EGFR: Cetuximab• HER-2/neu:Trastuzumab• VEGF:Bevacizumab• Small molecule inhibitors: Imatinib
• ;
Targeted Therapy
• Inoperable Tumors ( 60% of the patients)* Local spread( e.g tracheoesophageal fistula,)* Distant spread
• * Bad general condition• Options:-
– Endoscopic Laser to core a channel through the tumor
Palliative treatment
• Self expanding metal stents
• Traction stents e.g. Celestine stent
• Pulsion stents e.g. Soutter’ tube
Intubations
Dilatation
– Radiotherapy for squamous cell ca– Dose : 3000cGy /10 fractions /2 weeks– Reduced field / boost : 2000cGy/10# / 2 weeks– ILRT alone or in combination with EBRT. – 5 - 8Gy/# in 2- 3 fractions, one week apart– Chemotherapy :5 FU + Cisplatin– 5Fu 1000mg/m2/day continuous IV infusion on
day1-5Cisplatin 100mg/m2 iv on day 1– Repeat cycles on 1,5, 8, 11 wks
PEG
• Anastomotic leak• Respiratory insufficiency• Wound infection• Gastric outlet obstruction• Pulmonary embolism• Radiation pneumonitis• Stricture• Fistula • haemorrhage
Complications
Ms Shiney Sam
Nursing Management
• Preoperative management• Post operative management
Preoperative management
Psychological preparationAssess level of anxietyAnswer the questions and concerns regarding surgeryAllow time and privacy to prepare psychologicallyProvide support and assistanceCultural aspect need to be consideredDischarge planning
Legal preparation
Informed consent by surgeonNo sedation should be administered Documentation
Nutritional supportAims : promote wt gainInterventions– Assess wt , nutritional assessment– Sr Albumin , protein– Assessment of swallowing capacity– High calorie high protein diet in liquid and soft form– Enteral nutrition: NG feeds– Parentral nutrition– Hydration– Adjust diet according to existing problems-
constipation/diarrhea
Patients are not able to clear secretionsHead elevationStent placement and dilatation
Prevent pulmonary complications
Physical and physiological preparation
• Cleaning of surgical site• Shaving • Personal hygiene• Oral care• Nutrition: liquid diet x 3 days• Monitor vital signs• Intake /output chart• Antibiotics and regular medicationsNPO night beforeNo enema and laxatives can be allowed
Explain to notify pain Pain medications will be prescribedNon invasive pain relieve techniques
Pain management
Stop smokingChest physiotherapyIncentive spirometryFootball bladder exercisesCoughing exercisesDeep breathingSplintingGetting out of bed
Preoperative exercises
Pre anesthetic work upAll investigations & corrections toCo morbiditiesECGPFTArterial blood gas
2d echoMouth openingCheck listSend all equipments to OT
Post operative management
• Immediate• Intermediate• Extended
Immediate
• Intensive care - 24 to 48 hrs• Care of ventilated pt : patent airway
Suctioning
• Care of drains• Cardiopulmonary monitoring
Intermediate
• Neurological Status• Assess neurological status every
shift. • Any neurological change should be
carefully watched and• Promptly reported
Adequate pain control reduces the mortality and morbidity
Asess the pain Initial pain management consist of morphine or
bupivacaine given epidurally Patient-controlled analgesia with morphine, or a
combination of both .Nothing by mouth for 5 to 7 days, intravenous or
epidural pain medications are used.
Pain Management
Oral pain medications are started on the fifth or seventh postoperative day
The main classes : opoids, nonsteroidal anti-inflammatory drugs, and local anesthetics.
Pain Management contd..
Distraction RelaxationPositioning
Non-pharmacological interventions
Aggressive pulmonary toilet Pain control is paramount Patients are usually intubated after surgery
monitor oxygenation closely (spo2) Suctioning Chest physiotherapy ,Nebulizers Coughing, deep breathing exercises, Incentive
spirometer. Teach patients to splint their incision with a pillow. Early mobilization Monitor patients closely for fever
Pulmonary Care
Assess the drainage every shift.Serosanguinous within a few hours.Not more than 100 to 200 ml/h on the first day.A sudden change in the color of chest tube : milky (chyle leak ) Check the chest tube site for drainage, Keep the chest tube dressing clean, dry, and intact. Keep the chest tube free of any kinks or dependent loops
Chest tube care
Palpate the surrounding areaDue to an air leak from a pleural injury Additional suction or placement of a new chest tube New-onset may indicate a leak of the esophageal
anastomosis.. Fever, tachycardia, and hypoxemia Esophageal leak can be confirmed by barium
swallowPostoperative chest radiographs for pneumothorax
and for placement of any chest tube.Monitor abrupt changes in oxygenation
Subcutaneous emphysema
Hemodynamics
Intravenous maintenance fluid at a rate of 100 to 200 ml/h for the first 12 to 16 hours. Patients may require fluid boluses in the immediate postoperative period. Crystalloids or blood products may be used Interstitial pulmonary edema. Malnutrition and low protein levels can complicate the situation.A delicate balance between adequate fluid replacement and fluid overload. 30 ml/h of urine outputDetermination of body weight Meticulous skin care is necessary.
. Do not move, manipulate, or irrigate the nasogastric tube.Do not attempt to replace it. Monitor the tube for patency Assess the drainage for color and amount.
Nasogastric Tubes
Restricted by mouth for 5 to 7 days Oral medications, are crushed and put down the nasogastric tube on the second day ; they are never swallowed. Diligent mouth careA jejunostomy feeding tube is often placed during surgery and is used from the first post op day for feedingEarly enteral feeding helps in early healingJejunostomy site care
Gastrointestinal Care
At 5 to 7 days check the anastomosis for leaks Eat 6 to 8 small frequent meals each day, Avoid very hot or cold beverages and spicy foods. Protein supplements, high-energy foods, or a soft
dysphagia diet Sit upright, chew slowly, and eat more than 3 hours before
bedtime assists in reducing reflux. Drink fluids between meals rather than with meals Dumping syndrome, may arise in patients who have had
their vagus nerves divided. After vagotomy is related to unregulated gastric emptying
Minimizing liquids with meals Consumption of frequent, small, low-carbohydrate meals Discharged with plans for supplemental tube feeding.
Incision Care
Keep dressings clean, dry, and intact.Change dressing 2 to 3 times a daySaliva leak out through the cervical incision. Can be managed by simple dressingLarge volumes (>250 ml every 8 hours), application of a wound drainage bagThe leak is allowed to seal on its own,Sealing could take several weeks.
Compromised nutritional status, They have invasive catheters Risk of infection at the surgical sites. Meticulous wound and skin care, Hand washing, Avoidance of cross-contamination Changing of invasive catheters Antibiotics Adequate nutrition.
Infection Risk
Heparin s/c BDTED stockingsEarly ambulationLeg and ankle exercises
Prophylaxis of deep vein thrombosis
Discharge planning
• Do’sCheck surgical incisionMaintain personal hygieneIncision site careResume daily activities, work and sexual activities Drink fluid b/w mealsEat 3 hrs before bedtimeCheck wt
Take stool softenersCrush all medicationsObserve complications: tarry stool, progressive wt loss, diarrheaKeep follow up appointments
Contd…
• Don’tsAvoid smoking (join stop smoking group)Avoid strenuous activity for 12 wksAvoid driving for 3 wksAvoid hot & cold beverages , spicy foodDrink fluid in between meals
Patient must sleep in a head high position Get adapted to small frequent mealsKeep a difference of 2-3 hrs between meals and bed timeContinue spirometer for 3 monthsDonot carry weight more than 5 kgsResume daily activities
Rehabilitation
Prognosis
Every 6 monthsPlain X Ray, CBC , Biochemistry on visitIf symptomatic CT, PET CT
Follow up
Conclusion
Thank u