Rare esophageal cancer: case deemed inoperable, successfully treated with minimally invasive technique

An extensive tumor of the esophagus afflicted a 58-year-old patient from Naples. Given the extent of the neoplasm, the patient had been deemed inoperable by other specialists to whom he had turned but, after a careful evaluation of the clinical picture, the surgical team of the Santa Maria di Bari hospital, part of GVM Care & Research, led by dr. Antonio Braun developed the surgery that allowed the tumor to be removed.

The patient, a smoker (cigarette smoke is one of the main causes of esophageal cancer), was experiencing significant progressive weight loss, difficulty in ingesting solids and subsequently also liquids. The gastroscopy had found a 12cm neoplasm of the distal portion of the esophagus (the one closest to the stomach) which also infiltrated the cardia, or the junction between the esophagus and the stomach. The tumor had completely narrowed the esophagus so much that the patient was almost no longer able to eat and drink, leading him to anemia.

Esophageal cancer is a rare neoplasm, there are 3 cases per 100,000 inhabitants. It has a fairly aggressive behavior, precisely due to the anatomical structure of the esophagus itself”, explains Dr. Antonio Braun.

Previously, the patient had undergone a one-month cycle of preoperative chemotherapy, which however had no result either in reducing the volume of the tumor or in relieving the symptoms.

Ivor Lewis esophagectomy, the gold standard for the treatment of distal esophageal cancer, involves a double surgical approach, transthoracic and abdominal. This procedure allowed the radical removal of the tumor and above all the restoration of the patient’s digestive continuity, to allow him an independent and regular diet, which can be achieved gradually.

The operation, extremely complex due to the spread of the tumor, lasted 5 hours. The team adopted the technique according to Ivor Lewis because it is minimally invasive and particularly suitable for treating tumors in this site. The operation took place in two stages during the same operation: the first stage by laparoscopy to tubulize (resection of a vertical section) the stomach and remove the abdominal lymph nodes involved in the pathology. The second part of the operation, via thoracoscopy, allowed the tumor to be removed and an anastomosis to be performed, i.e. reconnecting the remaining esophagus to the stomach.

The minimally invasive access allows for a faster post-operative recovery compared to the 15-20 days required with the traditional method. Thanks to the application of recent clinical protocols (“fast-track” and “ERAS”), after a day in intensive care while awake, the patient returned to the ward and the nasogastric tube was removed, after two days he resumed drinking independently. Furthermore, mobilization took place on the second day, the abdominal and thoracic drains were removed on the 3rd and 5th postoperative days, respectively. The patient was discharged after 8 days.

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