By A/Prof Jimmy So, Senior Consultant, Department of Surgery, National University Hospital
Overview
Esophageal cancer can affect any parts of our esophagus. Esophagus is a muscular tube which serves as the passage of our food from our mouth to the stomach. It runs from your throat behind the trachea (windpipe), through the chest into the abdominal cavity. In the chest, it lies between your lungs and behind the heart. In Singapore, esophageal cancer is not common. However, this cancer has become more common in many western countries. The etiology of esophageal cancer is unknown. Smoking, alcohol and gastroesophageal reflux are the common predisposing factors. Esophageal resection is the primary treatment for localized esophageal cancer.
Symptoms
Difficulty of swallowing is the most usual symptom. Usually, there is a feeling that food is sticking on its way down to the stomach. At first, liquids are swallowed easily compared to solid food. There may also be some weight loss, and occasionally, pain or discomfort at the chest or the back. Other symptoms may include cough, vomiting and hoarseness of voice.
Diagnosis
The initial tests to diagnose an esophageal cancer is either an endoscopy or barium x-rays of the gastrointestinal tract.
In endoscopy, it allows the doctor to look directly at the esophagus through a thin flexible tube called an endoscope. The endoscope has a tiny camera at the end. If necessary, the doctor can take a small sample of the tissue (a biopsy) to be examined under a microscope.
For barium x-rays test, you will swallow a liquid containing barium. X ray pictures will be taken when the barium flows down the esophagus.
If a cancer is found, the next step is to find out whether the tumour has spread to other organs. The tests required may include chest x-rays, CT Scan (CAT Scan), endoscopic ultrasound and laparoscopy.
Treatment
Esophageal cancer can be treated by surgery, radiotherapy or chemotherapy. The treatments can be used alone or in combination. The choice of treatment will depend on the stage (or extent) of the cancer, the type of cancer, its position, as well as your age and general health.
Surgery
Surgery is a common treatment for esophageal cancer provided that the patient can withstand the surgery. It can cure the cancer if the cancer is at an early stage. It can be used as the only treatment or in combination with chemotherapy or radiotherapy. It is a major operation. Before surgery, make sure that you have discussed it fully with your doctor.
The most common operation is called radical esophagogastrectomy. In this operation, a chest wound is made where the tumour, most of the esophagus, top of the stomach and the surrounding lymph nodes are removed. Another wound in the abdomen is made to allow the stomach to join to the remaining part of esophagus (Figure 1). Moving the stomach in this way does not prevent you from eating normally after the surgery.
If it is not possible to use your stomach to replace your esophagus, a piece of the large intestine or small intestine will be used instead. In cases when the tumour is not removable at operation, the surgeon may insert a small feeding tube into the intestine to help you with the nutrition after surgery.
Figure 1. Position of stomach after esophagectomy
After Surgery
Esophageal surgery is a major operation. Most patients after an esophageal operation will be nursed in the intensive care or high dependency unit. This is purely routine and it allows doctors and nurses to monitor you more closely. Occasionally, the patients may be put on a ventilator, a machine which helps you to breathe, for a brief period of time after the operation.
At first, you may be given no fluids or drink or only sips of liquid for a few days. It allows the internal wound to be healed properly. Drips will be attached to your body to provide you with the fluid you required. Occasionally, a feeding tube will be inserted into the intestine to allow more calories to be given to you. There will be tubes and drains attached to the patients after esophageal surgery. A nasogastric tube, which passes down from the nose to your stomach is commonly placed. It removes the excess fluid in the stomach. Chest drains may be required too, these are tubes inserted into the chest to drain out fluids from your chest.
Patients with esophageal cancer can also receive other forms of treatment to relieve the difficulties of swallowing. The common recommendations include:
1. Intubation or stenting
It is a common way to improve the swallowing. A wire mesh tube (a stent) is placed into the esophagus using an endoscope. The procedure is similar to endoscopy. The tube is to keep the esophagus open to allow food passage. It allows you to eat more comfortably. This procedure is quite safe and the tube is usually durable and effective. At present, this tube is expensive. Our endoscopist will discuss with you in details.
2. Dilatation.
3. Endoscopic Ablation
Diet and Nutrition
Nutrition is essential to you. Before any treatment, a good nutrition speeds up the recovery. You may be referred to see our dieticians for advice on diet. You may have difficulty in swallowing solid foods. Hence, a liquid diet may be necessary. Sometimes, a feeding tube may be required to deliver more nutrition to you before or during the treatment.
After surgery, you may eat what you like as soon as the doctor says you may start eating again. You may feel full very quickly because your stomach will be smaller.
Our Approach and Expertise
Our approach is always multidisciplinary. Our team include surgeons, gastroenterologists, oncologists, radiotherapists and paramedical staffs such as dieticians. At the National University Cancer Institutite, Singapore, we have an Upper Gastro-Intestinal Multi-disciplinary Tumour Clinic. It is a one-stop clinic, where patients will be seen by physicians and surgeons at one setting.
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