Carcinoma Esophagus
The esophagus is a muscular tube also known as food pipe in general public transmits food material from mouth (base of pharynx) to the stomach. Carcinoma of esophagus is one of the deadliest malignancies of human body. The incidence of this malignancy is increasing in general population due to life style modification as well as changes in environment.
1. Squamous cell carcinoma – Cancer that forms in tissues lining the esophagus. Mostly found in upper and middle 1/3rd of esophagus. Incidence increases with age with most common age group between 55-60 years with male preponderance.
2. Adenocarcinoma – cancer that begins in esophageal lining cell that secret mucus. Most commonly found in lower esophagus and at the meeting point of esophagus and stomach. Commonly presented in patients with age group 50 years or younger.
1. Smoking and alcohol – smoking for a long duration and chronic alcohol consumption
2. Esophageal inner mucosal lining damage from physical agents –
- long term ingestion of hot liquids
- caustic ingestion (corrosive poisoning)
- radiation induced damage
3. Carcinogens in food and water – nitrates, nitrite, nitrosamine,
smoked opiates, fungal toxins in pickled
4. Obesity – increased risk for adenocarcinoma of esophagus. Incidence of gastroesophageal reflux increased in obesity due to lax lower esophageal junction to stomach which leads to Barrett’s esophagus. If condition is not reverted with time Barrett’s esophagus turns into malignancy.
5. Chronic iron deficiency anemia in females leading to plummer Vinson Syndrome
6. Congenital hyperkeratosis of palms and sole
7. Helicobactor pylori infection
8. Achalasia Cardia – long standing
9. Dietary deficiencies of molybdenum, Zinc, Vitamin A
1. Dysphagia – Dysphagia is the most common presentation. Patient may have difficulty in swallowing of solid food in early stage of disease and solid as well as
liquid food in the late stage of disease. 
2. Weight loss – recent onset and significant.
3. Coughing and choking during meal.
4. Change in voice – hoarseness.
5. Weakness and easy fatigability.
6. Pain behind sternum – occasional
7. Heart burn and reflux
8. Malena and sometimes haematemesis.
The patient is evaluated on the basis of history, symptoms and clinical signs. Along with routine blood test and X-ray some endoscopic and radiological investigations are done which include –
1. Barium sallow x- ray – thin barium is allowed to shallow and x-ray of esophagus taken. This shows the site and outline of tumor.
2. Endoscopy – the endoscope is passed through mouth to esophagus to see the inner lining of esophagus and tumor. If it shows any abnormal growth then a small piece of tissue from the growth is taken for confirmation of the diagnosis. These tissues are examined under a microscope for the presence of cancer.
3. Bronchoscopy – in cases of advanced tumor arising from upper ½ of esophageal an endoscope is passed into trachea (wind pipe) to rule out local spread of the tumor to lungs
4. Endoscopic Ultrasound – for early tumor endoscopic ultrasound is passed in esophagus to find out local spread of tumor.
5. For tumor staging radiological investigation like computed tomography (CT) scans of chest and abdomen and positron emission tomography (PET) scan are performed to determine outer spread of esophageal tumor to surrounding vital organs and distant spread to other organs.
6. Thoracoscopy and Laparoscopy – By this methods detection rate of lymphnodal and distal spread of esophageal malignancy is high.
Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body.
According to AJCC Cancer Staging Manual, Seventh Edition (2010) cancer growth and spread can be staged by TNM system
Tumor (T) – means how deep the tumor has grown into the wall of the esophagus
Node (N) – tumor spread to lymph nodes
Metastasis (M) – metastasis (distal spread) to other part of the body
Based on combined results of T, N and M staging of cancer determined.
Tumor (T) is classified into
TX: tumor cannot be evaluated
T0: cancer is not detected in the esophagus
Tis: this is also called carcinoma in situ that means very early cancer
T1: tumor spread to the lamina propria and submucosal layers of esophagus
T2: tumor spread to muscular is propria
T3: tumor spread to the adventitia, the outer layer of the esophagus
T4: tumor has spread to surrounding structures of the esophagus, including the aorta, pericardium, large blood vessel, trachea, diaphragm, and pleural lining of the lung
Node (N) : N stands for Lymph nodes. Lymph nodes close to esophagus is called regional lymph nodes and those located in other part of body are distant lymph nodes.
NX: lymph nodes cannot be evaluated
N0: cancer cells not detected in lymph nodes
N1: cancer cells has spread to 1-2 lymph nodes in the chest, near the tumor
N2: cancer cells has spread to 3-6 lymph nodes in the chest, near the tumor
N3: cancer cells has spread to 7 or more lymph nodes in the chest, near the tumor
this indicates whether the cancer cells has spread to other parts of the body
MX: Metastasis cannot be evaluated
M0: cancer cells has not spread to other parts of the body
M1: cancer cells has spread to another part of the body
G1: well differentiated
G2: mildly differentiated
G3: poorly differentiated
G4: not differentiated
There are separate staging systems for both squamous cell carcinoma and adenocarcinoma of esophagus.
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Staging of squamous cell carcinoma of the esophagus
Stage 0: Tis, N0, M0 Stage IA: T1, N0, M0 Stage IB: Stage IIA: Stage IIB: Stage IIIA: Stage IIIB: Stage IIIC: Stage IV : any T, any N, M1 |
Staging of adenocarcinoma of the esophagus
Stage 0: Tis, N0, M0 Stage IA: T1, N0, M0 Stage IB: Stage IIA: Stage IIB: Stage IIIA: Stage IIIB: Stage IIIC: Stage IV : any T, any N, M1 |
Patients with esophageal cancer are managed based on its staging. Overall general condition of the patients affects management.
Tis and T1aN0 stage –
Endoscopic therapy like mucosal resection or submucosal dissection with the help of endoscopic ultrasound (EUS),
Photodynamic therapy,
Radiofrequency ablation
T1b N0 & T2 N0 stage – Surgery (esophagectomy) to remove the part of esophagus that contains the cancer
Chemoradiation followed by surgery (trimodal therapy)
Patient with squamous cell carcinoma with well preserved general condition chemotherapy and radiotherapy started before definitive surgery.
Patients with adenocarcinoma of lower end esophagus where stomach meet (gastroesophageal junction) are only chemotherapy is given before surgery. For smaller tumor (< 2 cm) only surgery is advised.
Patients with serious co-morbidities who are not candidate for surgery are managed with chemoradiation.
Chemotherapy/ Radiotherapy or symptomatic and supportive care Treatment is given only for palliation to relieve the symptoms like pain, difficulties in swallowing etc.
Esophageal stenting (plastic/metallic) is done in situations where the patient is totally dysphagic and having esophagobroncheal fistula.
Patient who are unable to tolerate oral feeds a nasogastric tube may be required to continue feeding.
Some times gastrostomy/jejunostomy tube is required where patients become intolerant to nasogastric tube or tend to aspirate food.
Laser therapy is done in cases in which esophagus is totally occluded by cancer and the cancer cannot be removed by surgery. The relief of a blockage by laser can help to reduce dysphagia and pain
Chemotherapy may be given after surgery (adjuvant) to reduce risk of recurrence or before surgery (neoadjuvant) to down stage the disease.
Chemotherapy is cisplatin-based (or carboplatin or oxaliplatin) every three weeks with fluorouracil (5-FU) either continuously or every three weeks.
Recently epirubicin regimens is used in advanced nonresectable cancer.
Patients with adenocarcinoma with HER2 positive treated with targeted targeted therapy like trastuzumab.
Radiotherapy is given before, during or after chemotherapy or surgery. It is also used in palliation to control pain.
1. Locally advanced cancer engulfing adjacent vital structures like trachea, lung, pericardium, aorta recurrent laryngeal nerve
2. Esophageal Cancer with wide dissemination ( metastasis) to distant lymph nodes and vital organs
3. Severe co-morbidity involving cardiovascular and respiratory system
Surgery is performed by either open or minimal invasive method depending upon patient’s general condition and availability of experts. Now a days minimal invasive approach of esophagectomy has become very popular among surgeons because of low surgical morbidity, short hospital stay and similar onchological outcomes.
1. Transhiatal esophagectomy (THE)
2. Transthoracic esophagectomy (TTE) – thoraco abdominal Mc Keown’s & Ivor Lewis esophagectomy
In thoracoabdominal approach – both the abdominal and thoracic cavities opened together.
Ivor Lewis esophagectomy – two-stage approach involves an initial laparotomy and construction of a gastric tube, followed by a right thoracotomy to excise the tumor and create an esophagogastric anastomosis
McKeown esophagectomy – three-stage approach which include incision in the neck to complete the cervical anastomosis.
Details @ http://www.dr-pradeep-jain.in/
DR PRADEEP JAIN -WEIGHT LOSS SURGERY OR BARIATRIC SURGERY
Weight Loss Surgery or Bariatric Surgery
Bariatric surgery refers to the treatment of obesity. It is the best possible approach for those who cannot lose weight through exercise and diet alone. Being obese can invite number of health issues including high blood pressure, diabetes, joint problems and sleep apnea. Losing weight through surgical option typically results in dramatic and quick weight loss and significantly decreases the obesity related health issues like diabetes.
There are number of surgical procedures available to achieve weight loss. Dr. Pradeep Jain at Fortis Hospital specialized in bariatric surgery or weight loss surgery such as Laparoscopic Gastric Bypass, Laparoscopic Adjustable Gastric Banding and Laparoscopic Sleeve Gastrectomy.
After going through your medical history and diagnosis report, Dr Pradeep Jain Fortis Hospital will recommend an appropriate weight loss surgery.
Precautions after weight loss surgery
- You will on liquid diet for about 2 weeks
- You need to eat small meals, slowly and chew properly
- You need to maintain adequate hydration
- You must take daily recommended vitamin supplements
- Some may experience hair thinning that can improve by the adequate intake of protein and biotin supplements.
- You must do daily workout and must make right choice for your diet to ensure not to regain more weight
- You must regular follow up with your doctor, at least visit once in 3 months.
Laparoscopic Surgeries
Dr. Pradeep Jain is an experienced and specialized laparoscopic surgeon using high definition technology and precision equipment to perform laparoscopic treatments of gastrointestinal tract. Having years of experience and knowledge means better results for patients. Unlike conventional open surgeries, the laparoscopic surgeries involve:
- Early discharge from hospital
- Speedy recovery and early back to work
- Less pain
- Remarkably reduced bleeding
- Smaller or fewer scars
Dr. Pradeep Jain Fortis Hospital Review performs several kinds of laparoscopic surgeries including:
Laparoscopic Esophagectomy Surgery: The laparoscopic esophagectomy surgery is a minimal invasive surgery used to remove part or all esophagus due to the presence of cancer in it or also done for other non- cancerous conditions that makes esophagus non- functional. Esophagus is a tube presents in the throat and allow food to pass through it to stomach. After its removal, the esophagus is rebuilt from the part of large intestine or stomach. During the surgery, esophagus and stomach both are mobilized and doctor cut your stomach into the tube shape with the help of surgical staples. Several other ways are also available to perform this surgery Dr Pradeep Jain Fortis Hospital will recommend you which is best for you.
Laparoscopic Pancreatic surgery: Pancreatic surgery involves removing part or all of pancreas however, there are three types of surgery used to remove tumor of pancreas depending on the individual condition. Dr. Pradeep Jain Fortis Hospital performs whipple procedure for pancreatic, duodenal cancers or bile duct. He also performs laparoscopic distal pancreatectomy for pancreas cancer, pseudocysts and chronic pancreatitis or pancreatic cysts. Additionally pancreatic necrosectomy is done either by retroperitoneal or transperitoneal approach.
Laparoscopic Colorectal Surgery: Laparoscopic colorectal, hemicolectomy, APR and anterior resection is done for cancer of colon or rectum. The laparoscopic technique to treat these cancers are almost become a standard if performed by trained, professional and experienced surgeon likeDr. Pradeep Jain Fortis Hospital. The result of the procedure is same as of conventional open surgery however, complications and recovery are lower. Other indications include surgery for inflammatory bowel diseases such as colonic tuberculosis and rectopexy.
Laparoscopic Liver Surgeries: The laparoscopic liver surgeries are most commonly recommended for the presence of mass like abnormal growth and tumor. The liver surgeries are feasible with laparoscopic techniques but demanding technical expertise Dr. Pradeep Jain Fortis Hospital. The surgery can be done for primary and secondary tumors, cysts and hemangiomas etc.
Gastro-Intestinal Cancers
The term Gastro-Intestinal Cancer is refers to the cancer group that affect the human digestive system including gallbladder, stomach, liver, pancreas, oesophagus and bowel. It is the most common form of cancer and do not segregate between women and men. Just like any other health issue, the treatment for GI cancer will major depends on the cancer type, its stage and other health factors.
Although there are no specific symptoms that directly points towards cancers, some strong indicators include sever loss of weight and appetite, lump in abdomen, intestinal obstruction in elderly, alteration in bowel habits, prolonged bleeding from the GI tract and sudden detection of diabetes with weight loss etc.
Dr. Pradeep Jain Fortis Hospital is a specialized and experienced Gastro-Intestinal surgeon performing
- Colo Rectal Cancer
- Gastric cancers
- Pancreatic cancers
- Liver cancer
Details @ http://dr-pradeep-jain.in/
Pradeep Jain 