Carcinoma of the Esophagus Oluwole G. Ajao, MB, BS,FRCS,FMCS,FWACS, and Toriola F. Solanke, MB, ChB,ChM, FRCS, FICS, FMCS, FWACS Ibadan, Nigeria
Carcinoma of the esophagus, previously thought to be rare in West Africa, is now known to be relatively common in Ibadan. In a 39month period, extending from January 1975 to March 1978, 30 cases of esophageal carcinoma were seen on the surgical service of the University College Hospital, Ibadan. Males were affected more than females by a ratio of 2.3 to 1, and the highest incidence was found in the sixth and seventh decades. Many of the affected people belong to the low socioeconomic class. The predominant cell type is the squamous cell carcinoma and the most common site is the lower third of the esophagus (51.85 percent), followed by the mid-thoracic esophagus (29.6 percent). Because most patients presented very late in the course of the disease, only 11 patients had esophagectomy and esophagogastrostomy. Six of these (54.6 percent) recovered from the operation and were discharged. Only one patient had an insertion of a Mousseau-Barbin tube. In our environment, where there is no adequate radiotherapy facility, resection of esophageal carcinoma is recommended when feasible, even as a palliative measure.
Carcinoma of the esophagus was not seen too frequently about a decade ago in West Africa.1 This can be explained by the fact that until recently many people in West Africa went to traditional doctors instead of medical establishments for medical treatment. With the increase in both the level of mass education and the level of hospital consciousness, many diseases once thought to be uncommon in Africa, unfortunately are found to be not that uncommon.2 The purpose of this paper is to present our experience with 30 cases of carcinoma of the esophagus seen in Ibadan, and to advocate resection, even as a palliative measure, when possible. Resection is especially suitable in our environment, where radiotherapy or any other modality of treatment is not readily available.
Requests for reprints should be addressed to Dr. Oluwole G. Ajao, Department of Surgery, University of Ibadan and University College Hospital, Ibadan, Nigeria.
Clinical Material and Findings At the University College Hospital, Ibadan, in a 39-month period extending from January 1975 to March 1978, 30 cases of esophageal carcinoma were seen on the surgical service. This presentation does not include the few cases that defaulted after the initial visits, upon learning of the prognosis and possible complications of surgical intervention. The patients were between the ages of 39 and 80 years, with the highest incidence in the sixth and seventh decades (Table 1). The male-female ratio was 2.3 to 1. The duration of presentation extended from 1 to 12 months (Table 2). Twenty-three patients belonged to the low socioeconomic group and seven to the low-middle socioeconomic group in our society. Clinical presentation included dysphagia, regurgitation of food, weight loss, vomiting, epigastric pain, substernal pain, hiccups, anemia, dehydration, and cachexia. Some cases in
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which lesions were in the cervical esophagus presented with sore throat, cough, hoarseness of voice, and dyspnea. One patient with a cervical lesion also presented with hemoptysis. In this case, the esophageal lesion had involved the respiratory tract and the surrounding structures. The most common site for the location of the tumor in this series was the lower thoracic esophagus (51.85 percent), followed by the mid-thoracic (29.6 percent), upper thoracic (11. 1 percent), and cervical esophagus (7.4 percent) (Table 3). Ninety percent of cases in which histopathology was studied showed squamous cell carcinoma. Ten percent were adenocarcinomas. The histopathology of ten cases (these include those that refused any form of treatment) was not determined (Table 4). The two cases of adenocarcinoma arose in the lower third of the esophagus. One actually straddled the esophagogastric junction. Eleven patients (36.7 percent) had esophagectomy and esophagogastric anastomosis. Six of them (54.6 percent) made a full recovery and were discharged from the hospital. The length of survival of those discharged could not be ascertained because most of them returned to the sites of their initial referrals and were lost to follow-up. The other five (45.4 percent) died in the hospital. Two immediate postoperative deaths occurred 12 and 24 hours after resection. Three patients expired much later, on the 19th, 22nd, and 30th postoperative days. Complicatiorns encountered in some patients that had esophagectomy included aspiration pneumonia, empyema, postoperative psychosis, and laryngeal spasm. One patient developed massive subcutaneous emphysema over the entire chest wall 12 hours after surgery, even though the chest tube seemed to be functioning properly. This eventually subsided. Another patient, a heavy smoker, de703
Table 1. Carcinoma of Esophagus: Age Distribution (30 Cases)
Age in Years
Number of Cases
Percentage
30-39 40-49 50-59 60-69 Over 70 Total
1 2 13 10 4 30
3.3 6.7 43.3 33.3 13.3 99.9
Table 2. Carcinoma of Esophagus: Duration of Presentation (30 Cases) Duration in Months
Number of Cases
Percentage
Less than one 1-2 2-3 3-4 4-5 5-6 Over 6 Total
3 0 7 1 4 5 10 30
10 0 23.4 3.3 13.3 16.7 33.3 100.0
veloped unexplained laryngeal spasm postoperatively, necessitating a tracheotomy for about a week. Resection was not done in 19 patients (Table 5) either because they were too ill to have any major operation, or because they took their own discharges, or expired before work-up was completed. Five patients had only feeding gastrostomies. These were in so poor a shape that the gastrostomies had to be done under local anesthesia.3 All the cases of tracheal involvement had tracheostomies. Only one patient had the insertion of Mousseau-Barbin tube (Table 5). Initial biopsies during esophagoscopy gave false negative results in five cases.
Discussion
Table 3. Carcinoma of Esophagus: Various Locations (27 Cases)
Site
Number of Cases
Percentage
Cervical Upper thoracic Mid thoracic Lower thoracic Total
2
3 8 14 27
7.4 11.1 29.6 51.85 99.95
Table 4. Carcinoma of Esophagus: Histopathology of Cases (20 Cases)
Types
Number of Cases
Percentage
Squamous Adenocarcinoma Total
18 2 20
90 10 100
In our environment, carcinoma of the esophagus is more common in men than women by a ratio of 2.3 to 1, occuring mainly in the sixth and seventh decades. The predominant cell type is squamous cell carcinoma, although tumors anrsing very close to the esophagogastric junction tend to be adenocarcinoma. The most common lesion site in our series was the lower third where the prognosis is believed to be better than lesions at any other segment. The view is no longer held that the prognosis of esophageal carcinoma depends on whether the cell type is squamous or adenocarcinoma.4 Sweet5 recommended resection for carcinoma of the mid-thoracic and lower segments of the esophagus, even as a palliative procedure to relieve dysphagia. Lesions in the lower third are readily accessible by a left thoracotomy incision: lesions in the mid-thoracic esophagus by either a left or right thoracotomy incision: and lesions in the upper third of the esophagus by a right thoracotomy incision. Resection is accompanied by some form of esophagoplasty. For carcinoma, we prefer
Table 5. Carcinoma of Esophagus: Modality of Treatment (30 Cases)
Treatment
Exploration only Feeding gastrostomy only Esophagectomy and
esophagogastrostomy Mousseau-Barbin tube insertion No treatment Total
704
Number of Cases
Percentage
1 5 11
3.3 16.7
36.7
1
3.3
12 30
40.0 100.0
Immediate Postoperative Death
2
2
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A,
Figure 3. Barium swallow showing carcinoma of the lower third of the esophagus.
Figure 1. Barium swallow showing the stomach in the thoracic cavity after esophagectomy and esophagogastrostomy.
the use of the stomach to reconstruct the esophagus. This is pulled up into the thoracic cavity after mobilization (Figures 1 and 2). However, for corrosive esophageal stricture, which is relatively common, we routinely use a segment of the colon pedicled on an adequate colic artery.' If the stomach is used for esophageal reconstruction, it should be handled carefully. Only the necessary minimum mobilization should be done so as to retain the maximum blood supply to the stomach.7 For cervical esophageal carcinoma, laryngo-cervical esophagectomy combined, when indicated, with unilateral radical neck dissection and total thyroidectomy has been advised. Not all lesions were resectable in this series, even as a palliative measure. In this institution, most neoplasms are usually seen at very late and advanced stages.8 Cancer of the esophagus spreads longitudinally byway ofsubmucosal lymphatics, so that the tissue involvement is usually more extensive than the areas seen endoscopically or roentgenographically.9 Poor healing and leakage of the anastomosis tends to occur if the margin of resection is not free of
microscopic carcinoma. Super voltage radiation, either alone or
s.. ..
Figure 2. Barium swallowing showing the stomach in the thorax after esophagectomy and esophagogastrostomy for carcinoma of lower third of esophagus. As a palliative measure for inoperacoroiv espaiishv:ee lie bletoplyaprLntegnsso cases and in cases of further ~ obstruction after esophagogastrosespaga cacnm.9'11'1 tomy, the insertion of a MousseauBarbin or Celestin tube into the strictured area10 provides temporary relief from dysphagia. Feeding gastrostomies and tracheostomies, when indicated, are other supportive measures. The diagnosis of esophageal carcinoma can be established by barium swallow examination (Figure 3), esophagoscopy, and biopsy. The radiological pictures of other causes of dysphagia, eg, achalasia or benign esophageal stricture, are very different from those of esophageal carcinoma.6 Etiological factors believed to predispose to esophageal carcinoma include leukoplakia and frequent swallowing of a too large and too hard bolus of food which causes repeated minor trauma. Other causes include inflammation, thermal irritation, excessive use of alcohol, ingestion of spiced food, and use of tobacco. Mental and physical shock, emotional upset, esophagriti andt esophageal srnringv from
in combination with resection, is another modality for treating carcinoma of the esophagus. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 7, 1979
Conclusion Carcinoma of the esophagus is not rare in West Africa as was previously thought. Surgical resection is recommended when feasible, even as a palliative measure. The mortality of 45.4 percent for resection in this series can be reduced by early diagnosis, meticulous techmique at operation, and adequate postoperative care. Literature Cited 1. Solanke TF: Carcinoma of the esophagus in Ibadan. Int Surg 52:204-209, 1969 2. Ajao OG: Colon and anorectal neoplasm in a tropical African population. Int Surg, In press 3. Ajao 0G, Ladipo QA: The use of local anaesthetics for emergency abdominal operations. Trop Doct 8:73-75, 1978 4. Hankins JR, Cole EN, Attar 5, et al: Adenocarcinoma involving the oesophagus. J Thorac Cardiovasc Surg 68:148-158, 1974 5. Sweet RH: Late results of surgical treatment of carcinoma of the esophagus. JAMA 155:422425, 1954 6. Ajao 0G, Solanke TF: Benign esophageal stricture in a tropical African population. J Natl Med Assoc 70:497499, 1978 7. Adams HD: Malignant tumors of the esophagus and esophagogastric junction. Surg North Amer 44:585-587, 1964 dlin 8. Ajao OG: Vagotomy for relief of pain in some upper gastrointestinal neoplasms. J Natl Med Assoc 69:655-658, 1977 9. Watson WL, GoodmerJT: Carcinoma of the esophagus. Am J Surg 93:259-265, 1957 10. Balour TW: Intu bation of malignant oesophageal strictures. Lancet 1:1346-1347, 1974 11. deJong UW, Breslow N, Goh Ewe Hong J, et al: Aetiological factors in oesophageal cancer in Singapore Chinese. Int J Cancer 13:291 -303, 1974 12. Joske RA, Benedict EB: The role of benign esophageal obstruction in the development of carcinoma of the esophagus. Gastroenterology 36:749-755, 1959
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