ESOPHAGEAL TUMORS .

Eso tumors: Malignant > common than benign. Unfortunately, eso cancer discovered late & overall 5 y ear prognosis is bad < 10. Even for potentally resectable ca eso, 5 y survival is < 30%

Benign Neoplasms The most common is a gastrointestinal stromal tumour (GIST, another name for leimymoma),usually asymptomatic but may cause bleeding or dysphagia Uncommon, include fibrovascular polyps, leiomyomas, papillomas, lipomas, neurofibromas, granular cell tumors. When large, can cause dysphagia or chest pain from obstruction or stretch. Usually discovered incidentally.

LEIOMYOMA OF OESOPHAGUS Most common benign tumor of esophagus & small bowel but not common in the colon Usually asymptomatic May produce dysphagia or hematemesis if large. Typically occurs in young males Found most often in distal third of esophagus. Usually solitary, but may be multiple (3%). Imaging findings: Smooth, sharply-marginated mass. Well-defined, intramural (wall) mass &may narrow the lumen. May have coarse calcifications (only calcifying esophageal tumor) Rarely ulcerates

LEIOMYOMA OF OESOPHAGUS: diagnosis Barium swallow. Endoscopy: smooth submucosal lesion.

Ca esophagus.

ETIOLOGY & PATHOGENESIS. Almost all are adenocarcinoma or squamous cancers. Small-cell cancer is a rare third type.

SCC. In West relatively rare (4 cases /100 000), in Iran, Iraq Africa , China,common (200/100 000). Can arise in any part of the oesophagus from the post-cricoid region to the cardia. Almost all tumours above the lower third of the oesophagus are squamous cancers.

Adeno ca. Arises in the lower third of the oesophagus from Barrett's oesophagus or from the cardia of the stomach. The incidence is increasing & now 5:100 000 in UK; possibly because of the high prevalence of GERD/ Barrett's.

ETIOLOGY & PATHOGENESIS. > in men than women 3-4:1. Relatively common in Kurdistan. Should be considered in any case presenting with dysphagia.

SCC:Risk factors. Alcohol. Tobacco smoking. SCC of the head & neck. Lye or post-caustic strictures Achalasia. Papilloma virus infection. Plummer-Vinson syndrome Tylosis (familial hyperkeratosis of palms & soles) . Celiac disease. Radiation exposure. Post-cricoid web

SYMPTOMS. The most common is progressive dysphagia over a several-month period until only liquids can be taken. The obstruction does not occur until the cancer is far advanced. The dysphagia may be accompanied by a steady, boring pain, which often signals mediastinal involvement & inoperability. latex free aperture bars prevent epiglottis from occluding the lumen y holding it out of the way Only metal part is a spring in the valve “metal-free” version available for use in MRI

SYMPTOMS. Unexplained persistent chest pain should always be investigated by a careful double-contrast Barium or endoscopy. More advanced; halitosis & weight loss. Coughing after drinking fluid may be caused either by nearly complete esophageal lumen obstruction, with overspill into the larynx, or by the development of a tracheoesophageal fistula. Hematemesis & Hoarseness from involvement of the recurrent laryngeal nerve by tumor are unusual symptoms. latex free aperture bars prevent epiglottis from occluding the lumen y holding it out of the way Only metal part is a spring in the valve “metal-free” version available for use in MRI

SIGNS: Weight loss. Nail bed clubbing can be seen with both benign & malignant tumors. Vricho’s node in left supracalvicular region. Early diagnosis affords the only chance for cure. latex free aperture bars prevent epiglottis from occluding the lumen y holding it out of the way Only metal part is a spring in the valve “metal-free” version available for use in MRI

DIAGNOSIS. Preparation of the LMA Check patency of cuff- flexing LMA 180’ should not kink shaft fold cuff BACK smooth- away from aperture. Cuff should be flat w/ no wrinkles Cuff has “memory” Lubricate POSTERIOR surface only Surgilube v. lidocaine jelly (which contains preservatives-->sore throat/allergic rxn) Induction insertion requires depth similar to that which allows placement of oral airway propofol (2-2.5 mg/kg)v. STP (then deepen w/ inhaled) Etomidate not recommended Insertion of the LMA 1st- “sniffing position” 2 techniques to hold LMA- describe “hold like pencil then advance w/ index finger” using index finger to guide tube over the back of the tongue while stabilizing head w/ other hand-THEN GIVE MY TECHNIQUE place tip of LMA against hard palate under direct vision then, advance in one smooth movement until characteristic resistance is felt, which is upper esophageal sphincter if initial resistance-STOP- reposition against the hard palate immediately after insertion, LET GO and inflate the cuff. You should see characteristic outward movement of LMA as it centers itself around the laryngeal inlet with IPPV an audible leak at 15-20 cm H2O is common (which often disappears as hypopharyngeal mucosa molds around cuff perimeter HAS BEEN USED IN CASES UP TO & HOURS DURATION Securing secure neutral or straight down chin do not bend upwards use black line on tube as a visual check of position/orientation secure and protect against biting- can use rolled gauze sponges NEVER cut the tube Common Problems- if tip is not against hard palate, LMA may roll and fold on itself or roll up and jam against epiglottis other techniques: rotational movement, jaw thrust, bowl posterior or can use laryngoscope if too light laryngeal spasm/coughing/straining/breath holding/swallowing RX BY DEEPENING ANESTHETIC- by inhal or IV-REMOVING USUALLY MAKES IT WORSE! (MORE STIMULATION) too much air in the cuff will reduce the compliance of the cuff to form to the laryngeal inlet- it does not improve the seal N2O will diffuse into cuff over time (as short as 30”) CRICOID PRESSURE-increase angle of axes btwn LMA/trachea The investigation of choice is upper GI endoscopy with cytology & biopsy. A barium swallow demonstrates the site& length of the stricture but adds little useful information. Once a diagnosis has been achieved, investigations are performed to stage the tumour& define operability. Thoracic & abdominal CT are carried out to identify metastatic spread & local invasion. Invasion of the aorta&other local structures may preclude surgery. Unfortunately, CT tends to understage tumours &the most sensitive modality is EUS to define the TNM stage.

DIAGNOSIS. Dysphagia needs immediately double-contrast Barium. Preparation of the LMA Check patency of cuff- flexing LMA 180’ should not kink shaft fold cuff BACK smooth- away from aperture. Cuff should be flat w/ no wrinkles Cuff has “memory” Lubricate POSTERIOR surface only Surgilube v. lidocaine jelly (which contains preservatives-->sore throat/allergic rxn) Induction insertion requires depth similar to that which allows placement of oral airway propofol (2-2.5 mg/kg)v. STP (then deepen w/ inhaled) Etomidate not recommended Insertion of the LMA 1st- “sniffing position” 2 techniques to hold LMA- describe “hold like pencil then advance w/ index finger” using index finger to guide tube over the back of the tongue while stabilizing head w/ other hand-THEN GIVE MY TECHNIQUE place tip of LMA against hard palate under direct vision then, advance in one smooth movement until characteristic resistance is felt, which is upper esophageal sphincter if initial resistance-STOP- reposition against the hard palate immediately after insertion, LET GO and inflate the cuff. You should see characteristic outward movement of LMA as it centers itself around the laryngeal inlet with IPPV an audible leak at 15-20 cm H2O is common (which often disappears as hypopharyngeal mucosa molds around cuff perimeter HAS BEEN USED IN CASES UP TO & HOURS DURATION Securing secure neutral or straight down chin do not bend upwards use black line on tube as a visual check of position/orientation secure and protect against biting- can use rolled gauze sponges NEVER cut the tube Common Problems- if tip is not against hard palate, LMA may roll and fold on itself or roll up and jam against epiglottis other techniques: rotational movement, jaw thrust, bowl posterior or can use laryngoscope if too light laryngeal spasm/coughing/straining/breath holding/swallowing RX BY DEEPENING ANESTHETIC- by inhal or IV-REMOVING USUALLY MAKES IT WORSE! (MORE STIMULATION) too much air in the cuff will reduce the compliance of the cuff to form to the laryngeal inlet- it does not improve the seal N2O will diffuse into cuff over time (as short as 30”) CRICOID PRESSURE-increase angle of axes btwn LMA/trachea Dysphagia needs immediately double-contrast Barium. Any irregularity, esp if it narrows the lumen, mandates further evaluation. A bolus of barium-soaked bread may discover any possible sites of arrest. In the presence of suspicious symptoms & normal barium swallow results, endoscopy with biopsy & brushing of any suspicious lesion is indicated. The endoscopist should always obtain a good retroflexed view of the cardia from below, to make certain that an adenocarcinoma in GEJ has not been overlooked

DIAGNOSIS. If narrowing detected by barium swallow, endoscopy with biopsy & cytologic brushings of the involved area is required. Biopsy of visible tissue may reveal only inflammation; so as many as 6-9 deep biopsy specimens should be obtained. Maintenance do not use forceful bag squeezing, though slight (+) pressure is OK (give my opinion of spont vent) Forane or Sevo Removal remove when mouth opened on request do not ;leave syringe attached to valve, as premature deflation of balloon may occur watch for swallowing as an indication of returning airway reflexes Cleaning clean w/ warm water and bottle brush to remove all secretions/deposits cuff should be FULLY DEFLATED before autoclaving autoclave 121-134” for at least 3 minutes manufacturer guarantees 10 uses. some reports of >250 uses AVOID FORCEFUL REMOVAL OF THE DEVICE THROUGH A PARTIALLY OPENED MOUTH (life span goes way down)

DIAGNOSIS: staging. Evaluation for local tumor spread, mediastinal nodal involvement & liver metastases is essential for staging before a therapeutic decision is reached by: Physical examination for lymphadenopathy Tests of liver enzymes Chest radiography. CT scan. For upper & mid-esophageal tumors, bronchoscopy is indicated to evaluate for asymptomatic invasion of the tracheobronchial tree. Endoscopic ultrasound (EUS) is useful to detect the level of invasion & presence of mediastinal lymph node abnormalities & is becoming the favored test to determine if a lesion is resectable. reported as many as 250 uses

Awake Intub: can topicalize pt. and place awake. Difficult mask b/c of beard, large/small mandible, redundant tissue/big tongue Blind: distal aperture of LMA sits directly over the laryngeal inlet can pass an uncut, lubricated 6mm cuffed ETT through the mask rotate tube 90’ to left (CCW) during passage to bring bevel anterior to pass through aperture bars one study showed 72% success in avg 13 sec. and additional 12% after re-adjust. Later study by same author -->90% success w/ blind can also used a soft ETT changer (gum-rubber bougee) Failed: per Dr. Brain, LMA may be easier to insert when larynx is anterior (when tracheal intubation is most difficult) try before crich. low risk/benefit ratio per Benumof. full-stomach pt controversial cricoid pressure may make placement more difficult FOB: 5.0mm FOB will fit through #4 can be used as above in awake placement, or asleep. FOB can be used and then ETT passed over OR wire can be passed through suction port and used as a guidewire Unskilled: 2 studies: personnel w/ no previous experience using the LMA were successful in 90+% of cases NOT USEFUL IF PT HAS LIMITED MOUTH OPENING

The tumour (T) has extended through oeso wall (stage T3). Awake Intub: can topicalize pt. and place awake. Difficult mask b/c of beard, large/small mandible, redundant tissue/big tongue Blind: distal aperture of LMA sits directly over the laryngeal inlet can pass an uncut, lubricated 6mm cuffed ETT through the mask rotate tube 90’ to left (CCW) during passage to bring bevel anterior to pass through aperture bars one study showed 72% success in avg 13 sec. and additional 12% after re-adjust. Later study by same author -->90% success w/ blind can also used a soft ETT changer (gum-rubber bougee) Failed: per Dr. Brain, LMA may be easier to insert when larynx is anterior (when tracheal intubation is most difficult) try before crich. low risk/benefit ratio per Benumof. full-stomach pt controversial cricoid pressure may make placement more difficult FOB: 5.0mm FOB will fit through #4 can be used as above in awake placement, or asleep. FOB can be used and then ETT passed over OR wire can be passed through suction port and used as a guidewire Unskilled: 2 studies: personnel w/ no previous experience using the LMA were successful in 90+% of cases NOT USEFUL IF PT HAS LIMITED MOUTH OPENING The tumour (T) has extended through oeso wall (stage T3). A small peri-tumoral lymph node (LN) is also seen.

Awake Intub: can topicalize pt. and place awake. Difficult mask b/c of beard, large/small mandible, redundant tissue/big tongue Blind: distal aperture of LMA sits directly over the laryngeal inlet can pass an uncut, lubricated 6mm cuffed ETT through the mask rotate tube 90’ to left (CCW) during passage to bring bevel anterior to pass through aperture bars one study showed 72% success in avg 13 sec. and additional 12% after re-adjust. Later study by same author -->90% success w/ blind can also used a soft ETT changer (gum-rubber bougee) Failed: per Dr. Brain, LMA may be easier to insert when larynx is anterior (when tracheal intubation is most difficult) try before crich. low risk/benefit ratio per Benumof. full-stomach pt controversial cricoid pressure may make placement more difficult FOB: 5.0mm FOB will fit through #4 can be used as above in awake placement, or asleep. FOB can be used and then ETT passed over OR wire can be passed through suction port and used as a guidewire Unskilled: 2 studies: personnel w/ no previous experience using the LMA were successful in 90+% of cases NOT USEFUL IF PT HAS LIMITED MOUTH OPENING

TREATMENT. Choice of therapy depends on: Location Size Presence or absence of spread. Cell type. greater anesthetic depth is required in a child than when inserting an oral airway recommended that LMA only be inserted in spontaneously breathing children breath holding and laryngospasm may be mistaken for incorrect position but usually result from inadequate anesthesia intubation through LMA in children always preceded by FOB inspection b/c epiglottis can be folded down or included in bowl of mask

TREATMENT. Surgical resection of SCC & adenocarcinoma of the lower 1/3 is preferred unless widespread metastases present. Surgery offers the benefit of rapidly restoring esophagogastric continuity. Only 1/4 have a resectable tumor; of these, 10 - 20% do not survive the operative period. 5-year survival is only 5 - 20%, even with extensive resection. Long-term survival cannot be predicted in the individual case by the operative findings. There is growing enthusiasm for palliative resection with restoration of GI continuity with stomach or colon. greater anesthetic depth is required in a child than when inserting an oral airway recommended that LMA only be inserted in spontaneously breathing children breath holding and laryngospasm may be mistaken for incorrect position but usually result from inadequate anesthesia intubation through LMA in children always preceded by FOB inspection b/c epiglottis can be folded down or included in bowl of mask

TREATMENT. Radiation therapy +/- surgery or chemotherapy has been a mainstay for SCC, but adenocarcinomas are relatively radioinsensitive. Radiotherapy has little hospital mortality, but some short-term & long-term morbidity. Patients treated with definitive radiation therapy (50 to 80 Gy) alone have a 1-year survival of 18-40% & a 5-year survival of 6-14% dependent on the initial stage. greater anesthetic depth is required in a child than when inserting an oral airway recommended that LMA only be inserted in spontaneously breathing children breath holding and laryngospasm may be mistaken for incorrect position but usually result from inadequate anesthesia intubation through LMA in children always preceded by FOB inspection b/c epiglottis can be folded down or included in bowl of mask

TREATMENT. Chemotherapy with cisplatin-containing combinations has demonstrated objective tumor response. Multimodality treatment with radiation + chemotherapy with cisplatin - fluorouracil is superior to radiation therapy alone. When obvious extraesophageal spread is present, palliation may be achieved with bougienage dilation+/- Endoscopic metalic stenting to restore & maintain an adequate esophageal lumen. If performed with a guide wire under fluoroscopic guidance, is not hazardous in skilled hands. greater anesthetic depth is required in a child than when inserting an oral airway recommended that LMA only be inserted in spontaneously breathing children breath holding and laryngospasm may be mistaken for incorrect position but usually result from inadequate anesthesia intubation through LMA in children always preceded by FOB inspection b/c epiglottis can be folded down or included in bowl of mask

TREATMENT. If dilation does not offer lasting relief, then a Silastic tube or metal stent can be placed perorally to relieve esophageal obstruction&greatly beneficial in treating malignant tracheoesophageal fistula. Destruction of intraluminal tumor & restoration of an adequate lumen may be performed by endoscopic laser therapy, intraluminal heat-coagulating probe, or photodynamic therapy. greater anesthetic depth is required in a child than when inserting an oral airway recommended that LMA only be inserted in spontaneously breathing children breath holding and laryngospasm may be mistaken for incorrect position but usually result from inadequate anesthesia intubation through LMA in children always preceded by FOB inspection b/c epiglottis can be folded down or included in bowl of mask

TREATMENT. Despite modern treatment, the overall 5-year survival of oesophageal cancer is 6-9%. Survival following oesophageal resection depends on stage. Tumours which have extended beyond the wall,have lymph node involvement (T3, N1) are associated with a 5-year survival of around 10% after surgery. Without LNs, Overall survival following 'potentially curative' surgery (all macroscopic tumour removed) is about 30% at 5 years& can be improved by neoadjuvant (pre-operative) chemotherapy with agents as cisplatin/ 5-fluorouracil. greater anesthetic depth is required in a child than when inserting an oral airway recommended that LMA only be inserted in spontaneously breathing children breath holding and laryngospasm may be mistaken for incorrect position but usually result from inadequate anesthesia intubation through LMA in children always preceded by FOB inspection b/c epiglottis can be folded down or included in bowl of mask

TREATMENT. Although SCC are radiosensitive, radiotherapy alone is associated with a 5-year survival of only 5%. 70% have extensive disease at presentation; in these, treatment is palliative & based upon relief of dysphagia &pain. Endoscopically directed tumour ablation using laser therapy or insertion of stents is the major method of improving swallowing. Palliative radiotherapy may induce shrinkage of both SCC/ adenocarcinomas but symptomatic response may be slow. Quality of life can be improved by nutritional support /appropriate analgesia. greater anesthetic depth is required in a child than when inserting an oral airway recommended that LMA only be inserted in spontaneously breathing children breath holding and laryngospasm may be mistaken for incorrect position but usually result from inadequate anesthesia intubation through LMA in children always preceded by FOB inspection b/c epiglottis can be folded down or included in bowl of mask

ADENOCARCINOMA: A rapid rise in adenocarcinoma, particularly in white men, has made their current cancer rates about equal. Unlike SCC, arise in the distal esophagus because of the presence of Barrett’s eso, a complication of GERD. Lymphatic spread is common. Adenocarcinomas are radio insensitive; although chemoradiation &surgery may improve survival, the 5-year survival < 10% almost equal to SCC. Palliation is the same as for inoperable SCC. greater anesthetic depth is required in a child than when inserting an oral airway recommended that LMA only be inserted in spontaneously breathing children breath holding and laryngospasm may be mistaken for incorrect position but usually result from inadequate anesthesia intubation through LMA in children always preceded by FOB inspection b/c epiglottis can be folded down or included in bowl of mask

ADENOCARCINOMA in a Barret’s : greater anesthetic depth is required in a child than when inserting an oral airway recommended that LMA only be inserted in spontaneously breathing children breath holding and laryngospasm may be mistaken for incorrect position but usually result from inadequate anesthesia intubation through LMA in children always preceded by FOB inspection b/c epiglottis can be folded down or included in bowl of mask