Esophageal Cancer: When the Grim Reaper Darkens Your Door Part III

Treatment is finally scheduled. I should be happy about that but…

We finally have a start date for chemo and radiation in mid-September. The radiation is the heavy lifter in this treatment plan and the chemo is supposed to make the radiation more successful. This is penciled -in for five weeks. This will be followed by four to six weeks of waiting and then will be followed by surgery. Said surgery is just in time for the beginning of the holidays. And then everything is all better, or so my wife claims.  (She keeps using variations of the word, “cured”.)

Folks, if having esophageal cancer was really this easy, then why are half of all patients diagnosed with this cancer, dead within 13 to 18 months of diagnosis? I guess in polite company we don’t ask, and they won’t volunteer it.

For those willing to listen, the talk with the radiologist was measured and cautious. No, “you probably won’t get burns on your skin” and “your hair probably won’t fall out”. Then the comment about “if you’re healthy enough, you can have surgery.”

Of course, the treatment is to shrink to tumor and then allow for surgery. “Yes, radiation shrinks the tumor, but you may develop sores in your esophagus that prevent you from eating what you want.”

The chemo/radiation treatments will decimate my wife’s immune system and necessitates locking down all household members in a manner that sounds suspiciously like the two weeks to flatten the curve nonsense inflicted on us during the spring of 2020. However, unlike then, wipes and toilet paper are easily obtainable. During this time, our son gets to go to school and back, while I’m the designated grocery shopper. My wife is expected to lose 20 to 25 pounds during this period of time and that’s without the doctor knowing that I will be the designated cook for much of this time.

As for the surgery, my wife has it in her head that it will be laparoscopic in nature and over in a short period of time. Color me skeptical. We will know in a few days when we meet with the surgeon.

Update after meeting with the surgeon.

The surgeon says the procedure must be performed between five to ten weeks after the end of the radiation treatments. Five weeks is to allow the presence and effects of chemo to dissipate and probably allow the immune system to recover slightly. The ten-week limit is due to the fact that irradiated tissue will become scare tissue making the success of the surgical procedure unlikely.

Now for the procedure itself. Here are some quotes related to what is scheduled to happen.

Surgery to remove some or most of the esophagus is called an esophagectomy. If the cancer has not yet spread far beyond the esophagus, removing the esophagus (and nearby lymph nodes) may cure the cancer. Unfortunately, most esophageal cancers are not found early enough for doctors to cure them with surgery.

Often a small part of the stomach is removed as well. The upper part of the esophagus is then connected to the remaining part of the stomach. Part of the stomach is pulled up into the chest or neck to become the new esophagus.

How much of the esophagus is removed depends upon the stage of the tumor and where it’s located:

If the cancer is in the lower part of the esophagus (near the stomach) or at the place where the esophagus and stomach meet (the gastroesophageal or GE junction), the surgeon will remove part of the stomach, the part of the esophagus containing the cancer, and about 3 to 4 inches (about 7.6 to 10 cm) of normal esophagus above this. Then the stomach is connected to what is left of the esophagus either high in the chest or in the neck.

Surgery for Esophageal Cancer

The surgeon described the procedure as a transthoracic esophagectomy. This method is also known as the Ivor Lewis Esophagectomy. The technique was originally developed in 1946.

A transthoracic esophagectomy, also known as an Ivor Lewis esophagectomy, is a procedure in which part of the esophagus is removed. During this surgery, small incisions are made in the chest and another is made on the abdomen. The cancerous portion of the esophagus is removed, along with the surrounding lymph nodes and a small margin of healthy tissue above and below the tumor. The stomach is made into a cylinder, pulled up into the chest and connected to the remaining section of the esophagus.

Transthoracic (Ivor Lewis) Esophagectomy

Illustrations of the procedure can be found at Technique of Open Ivor Lewis Esophagectomy. Please read descriptions of the various drawings to get a better idea of the procedure.

Pre-Surgical Complications

The surgery has a few points of deciding go or no-go on going thru with the procedure.

Is patient physically able to undergo the surgery after the pounding their body endures from the chemo and radiation?

Does the presurgical PET scan show any spread of the cancer since patient has had the chemo and radiation treatment?

Surgical Complications

When surgery begins, following the incision into the chest and stomach area, the doctor does a visual inspection of tissues surrounding the cancerous area. If cancer has spread, then the surgery is aborted before it proceeds further.

The operation begins with an esophagoscopy to confirm the extent of tumor. On opening the abdomen, the right gastroepiploic artery is palpated and its fitness as the blood supply for the gastric conduit is confirmed. Abdominal exploration should confirm absence of liver metastases, extensive nodal disease, omental metastases, etc.

Technique of Open Ivor Lewis Esophagectomy

Post-Surgical Complications

Comparison of complications reported in a recent series is hindered by the lack of uniform definitions of complications, the nonreporting of events, and the mixture of surgical approaches in some of the reports. The incidence of pneumonia has varied from 8% to 26%. Anastomotic leak has been detected in 3% to 8%. Mortality has varied between 1.4% and 10%. It is also known that esophagectomy is a procedure that is affected by hospital and surgeon volumes.

The surgeon said that a hospital stay of 7 or more days was common. Per reading that I have done, some post operative complication is likely. Per the American Cancer Society, here are likely risks:

  • Short-term risks include reactions to anesthesia, more bleeding than expected, blood clots in the lungs or elsewhere, and infections. Most people will have at least some pain after the operation, which can usually be helped with pain medicines.
  • Lung complications are common. Pneumonia may develop, leading to a longer hospital stay, and sometimes even death.
  • Some people might have voice changes after the surgery.
  • There may be a leak at the place where the stomach (or intestine) is connected to the esophagus, which might require another operation to fix. This is not as common as it used to be because of improvements in surgical techniques.
  • Strictures (narrowing) can form where the esophagus is surgically connected to the stomach, which can cause problems swallowing for some patients. To relieve this symptom, these strictures can be expanded during an upper endoscopy procedure.
  • After surgery, the stomach may empty too slowly because the nerves that cause it to contract can be damaged by surgery. This can sometimes lead to frequent nausea and vomiting.
  • After surgery, bile and stomach contents can back up into the esophagus because the ring-shaped muscle that normally keeps them inside the stomach (the lower esophageal sphincter) is often removed or changed by the surgery. This can cause symptoms such as heartburn. Sometimes antacids or motility drugs can help these symptoms.

Conclusion … for now.

Now that I have described what lies ahead, I have a few closing comments.

My wife continues to display signs that the cancer is still growing. She has more difficulty swallowing than a few weeks ago and each night she is now afflicted with lots of acid reflux after going to bed. She believes (and based on what I see, I agree) that her stomach is no longer sealing, (sphincter muscle is no longer closing her stomach). She believes that her tumor is preventing this system from working correctly.

I will update you further as we progress thru this treatment. I still remain pessimistic, but as I am but a spectator in the drama, which is about to unfold, my opinion is of limited value.

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