In September 2005, my husband William was diagnosed with adenocarcinoma of the esophagogastric junction (AEG). Less than 10 months later, he died from surgical complications. William had a longstanding history of acid reflux and Barrett’s esophagus (a complication of gastroesophageal reflux disease), which we thought was well controlled. After his death, when I began more in-depth research about this silent killer, I recognized the need for greater public and healthcare-professional awareness of this devastating disease. Consumer education, media attention, and researchers have focused extensively on breast cancer in women, while AEG in white American males gets little attention.
Early diagnosis may bring a more positive outcome, but postoperative quality of life declines severely. For instance, eating—for most people, a pleasurable and social function—becomes difficult due to swallowing problems and smaller gastric capacity. Patients have trouble maintaining optimal nutrition.
Esophageal cancer is three to four times more prevalent in men than women. Squamous-cell carcinoma is the most common esophageal cancer in African-American males, whereas adenocarcinoma is more common in white males.
Esophageal cancer incidence is growing at an alarming rate. In the western world, AEG is the most rapidly increasing cancer. In white American males, its incidence is climbing faster than that of any other cancer. Since the mid-1970s, it has risen steadily by 5% to 10% per year.
According to the American Cancer Society (ACS), esophageal cancer kills approximately 14,000 Americans each year. Worldwide, it’s is the sixth leading cause of death, with 400,000 cases diagnosed annually. Esophageal cancers cause more deaths globally than breast, lung, or colorectal cancer. AEG has a mortality rate of 87%.
Survival rates for esophageal cancer have improved since the 1950s but remain low. Today, only about 17% of whites and 12% of African-Americans survive at least 5 years after diagnosis; these rates apply to all disease stages.
Early diagnosis may lead to higher survival rates but doesn’t guarantee longer survival. Survival depends on an individualized therapeutic approach based on tumor type and staging results, along with the extent and type of treatment complications. Complications stemming from leaks at the anastomotic site almost always are fatal.
Research shows that reflux symptoms and Barrett’s esophagus relate closely to an increased adenocarcinoma risk. Most esophageal adenocarcinomas arising in the lower third of the esophagus result from preexisting Barrett’s esophagus.
Typically, AEG progresses as shown in the box below:
Adenocarcinoma incidence in patients with Barrett’s esophagus is thought to be less than 5% or 10%. But this is just an estimate; the true incidence of Barrett’s esophagus is unknown.
Surgical resection is the optimal approach in patients with early resectable AEG who have no evidence of metatastic disease and are physically fit enough to undergo the difficult surgery. The ideal approach is complete resection of the tumor and its lymphatics to provide the best potential for long-term survival.
Preoperative staging is extremely important in determining appropriate treatment. Endoscopy with biopsy is the mainstay of diagnosis. Modalities used to assess disease extent are spiral computed tomography (CT); endoscopic ultrasound (EUS), including EUS fine-needle aspiration; and positron emission tomography. The patient’s physical fitness and expected ability to withstand surgery also must be considered.
Generally, AEG is treated as follows:
- Stage I tumors with no metastasis warrant limited resection of the proximal stomach and distal esophagus.
- In more advanced but resectable stage I tumors, the tumor and its lymphatics are removed completely.
- In Stage II or III tumors, total gastrectomy with trans-hiatal resection of the distal esophagus may be done, along with en-bloc removal of the lymphatic drainage system.
- For locally advanced tumors when complete surgical removal is questionable, multimodal treatment trials should be considered. Optimal treatment is controversial. Chemoradiation or surgery alone are acceptable standards of care, with treatment selection based on the patient’s tumor stage and comorbidities.
- Metastatic or unresectable disease is incurable. Chemotherapy is palliative, with the goal of improving quality of life and easing dysphagia in about 60% to 80% of patients. Median overall survival is 4 to 8 months. Chemotherapy doesn’t yield a survival benefit in advanced disease, although it does in metastatic gastric cancer. Neoadjuvant and adjuvant multimodalities and definitive chemoradiotherapy are promising but need further investigation.
Surgical approaches and complications
Surgical approaches include the left thoraco-abdominal, Ivor Lewis, transhiatal, right thoracotomy/transhiatal and retrosternal approaches. Regardless of the technique used, esophagogastric resection is difficult and fraught with complications. In many cases, comorbidities complicate the postoperative course.
One of the newest surgical modalities for AEG is the minimally invasive DaVinci Robotic technique. Data suggest it significantly reduces recovery time, pain, trauma, and infection risks. Yet it’s no panacea. Critical factors for good patient outcomes include the surgeon’s experience using the robot for complex surgeries, critical-care nurses’ experience caring for patients who’ve undergone robotic surgery, anesthesia care, and hospital volume in handling complicated cases. Little data exist on the costs and benefits of robotic surgery for this type AEG cancer compared to conventional techniques.
In elderly patients undergoing complex surgeries such as esophagogastrectomy and pancreatectomy, mortality relates directly to how many such procedures are done at the hospital in question. Generally, mortality is lower when complex procedures are performed at high-volume hospitals and the patient receives care from an experienced surgical team. Between 1988 and 1998, mortality rates for esophageal resection in low-volume centers ranged from 9.2% to 20.3%; high-volume centers had lower mortality rates, ranging from 2.5% to 8.4%. Such organizations as the LeapFrog Group (a patient-safety program) recommend that esophageal resection be performed only at high-volume centers—those with least 20 resections per year.
Efforts to enhance surgical outcomes typically focus on improving preoperative patient selection and reducing postoperative complications. Only a few studies have examined how complications associated with surgical technique relate to outcomes in cancer patients who’ve had esophagogastrectomies.
One of the most serious complications of esophagogastric resection is an anastomotic leak—dehiscence at the stomach-esophagus anastomosis. This complication leads to sepsis, mediastinitis, empyema, and multiple organ failure and increases mortality exponentially. Incidence of leaks varies widely; a 2011 study showed an incidence of 10% to 20%. (My husband died from an anastomotic leak 9 months after robotic surgery.)
Research shows anastomotic leaks relate directly to surgical technique. About 78% of technical complications included a leak directly attributable to surgical technique. One study of cancer patients who’d undergone esophagogastric resection found 147 complications related to surgical technique in 138 patients; 21% (106) of patients experienced anastomotic leaks. They had poorer outcomes and a substantially lower survival rate.
Preoperatively, teach patients who will undergo robotic surgery about the postoperative course, including expected pain level, permissible activity level, possible complications, and surgical-site care. To the extent possible, answer their questions about the robotic procedure and surgical equipment. However, be aware that little patient-education material is available other than generic resources from manufacturers.
Explain that the robotic system is not a preprogrammed medical device that performs on its own. Reinforce the surgeon’s explanation of why he or she believes the robotic technique will benefit the patient—for example, promoting a shorter hospital stay, reducing pain, and allowing a faster return to normal activities. Tailor your teaching to each patient.
Postoperatively, the same standards of care apply whether the patient had a robotic procedure or a traditional open procedure. Patients who’ve had the robotic procedure typically stay in the hospital for approximately 6 days; those who’ve had a traditional open procedure usually stay 10 to 14 days.
Inform the patient that before discharge, a gastrografin swallow test is done to rule out an anastomotic leak. If no leak is found, the patient will be started on a clear liquid and advanced to soft foods as tolerated. If a leak is suspected, jejunostomy tube feedings may be started.
Activity levels are based on how the patient feels. Caution patients against heavy lifting or driving until the first postoperative visit (usually a week after discharge). Advise patients and family members to monitor the incision site and report drainage, and to keep the dressing dry and intact.
Healthcare professionals need to raise public awareness of AEG, especially among men, to encourage early diagnosis and treatment of upper GI symptoms and help guide selection of treatment options. Early diagnosis is crucial. Equally important, if surgery is warranted, it should be done in a high-volume facility to optimize the chance for recovery and quality of life.
Valera A. Hascup is an assistant professor of nursing at Kean University in Union, New Jersey and a nurse researcher at Somerset Medical Center in Somerville, New Jersey.
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