What is an Esophagogastrectomy? An Esophagogastrectomy is surgery to remove the esophagus and part of the stomach. The esophagus is then replaced in one of two ways: by moving the remaining portion of the stomach upwards, or by replacing it with a section of the large bowel (colonic reconstruction). Lymph nodes near the esophagus may also need to be removed.

This surgery is typically done for people with esophageal cancer or people with Barrett’s Esophagitis, who are at high risk for developing esophageal cancer. This operation removes the diseased portion of the esophagus. Swallowing problems or dysphagia are common in people with esophageal cancer. Often times these swallowing problems cause people to have a difficult time eating. Surgery should help reduce swallowing problems.

Purpose of the surgery may be to remove all of the cancer, or the diseased area or it may be to help lessen your symptoms.

What Happens Before Surgery? Your surgeon will do a physical exam before your surgery. You may need an evaluation by a cardiologist (heart specialist) or a pulmonologist (lung specialist). As with any surgery, there is a chance you may need a blood transfusion. If you would like, you or a family member can donate blood before the surgery. You will be on a clear liquid diet the day before the surgery. You will also need to take a laxative and probably a “bowel prep”. A bowel prep helps to clear out your bowel needed before surgery. Your doctor may have you take antibiotics before surgery. Do not eat or drink after midnight the night before your surgery.

You will have several tubes after your surgery: • Nasogastric Tube (NG)

A plastic tube is inserted through your nose and down your throat into your stomach. This tube will suction secretions out of the stomach and this helps the site to heal. It is very important that this tube is not moved or pulled in any way. The tube staying in place will help ensure proper healing of the surgical area inside your body. You will not be allowed to eat or drink while this tube is in place. The healing of the surgical area often takes 7-10 days. The doctor will decide when to remove the nasogastric tube based on several factors.

The Radiology Leak Study also called a "swallow study" is done in fluoroscopy when ordered by your physician. You will be given liquids to drink and x-rays will be taken to check the healing inside your throat. Usually, your doctor will want you to keep the NG tube in until you have good results on the swallowing study. When you are able to swallow well enough, and the surgical areas have healed enough, your doctor may decide to remove your tube. Then you can begin to eat certain foods. You will have teaching about foods to eat.

If you are not yet able to swallow well enough, your doctor may have you continue with the tube feeding until you heal more. The swallow test will be done again later to see if the tube can be removed.

Jejunostomy Tube:

A J-tube is a soft, red, rubber tube that is placed during surgery into a part of your small bowel (jejunum). It is used to feed you temporarily until you are able to eat. The tube feedings are often started on the second day after surgery. If you need help with getting more nutrition, you may still need to have tube feedings for a few weeks.

Foley Catheter

This tube goes into your bladder to drain your urine. Most patients need this for 3 - 4 days. It may stay in longer if you have an epidural catheter.

Jackson Pratt Drains

You will have two drainage tubes in the right side of your abdomen that are connected to small bulb containers. These tubes drain the extra fluid from the surgical area.

Chest Tube

You may have a chest tube after your surgery. Your lungs may be stressed or affected by the surgery because the esophagus is located between your lungs. You may have a chest tube after surgery to collect fluid from in or around your lungs. While the tube is in place you will have an x-ray in your room each morning. This x-ray helps the doctor's determine when the tube can be removed from your lungs.

Epidural Catheter

This small catheter or tube is used to give you pain medicine after your operation. Before surgery, the anesthesiologist will discuss this method for pain relief. Before you go to sleep, the anesthesiologist will put the tube into the space around your spinal cord (epidural space). A continuous infusion of pain medicine is given through this tube. This tube stays in until you can take pain medicine by mouth. PCA Pump A PCA pump is another way to give you pain medicine. It is used if you cannot have or do not want an epidural. This pump is connected to your IV. You press a button to regulate when you get your pain medicine. Only you, the patient, should ever press this button. The pump does not allow too much medicine to be given. A PCA pump is continued until you are able to take pain medicine by mouth.

Walking helps to prevent blood clots, pneumonia and speeds up your recovery. Another way to prevent blood clots is through the use of a compression device on your legs. This device consists of cuffs that are wrapped around your legs and are then attached to a machine. The machine regulates the cuffs to compress and release which helps the circulation (flow) of blood in your legs.

Nutrition Before you are able to try to eat and drink, your bowels must start moving and the surgical sites inside your throat and stomach area must have had enough time to heal. Many patients find it hard to wait, but this usually takes 7-10 days. As long as you are not able to eat and drink as much as you normally would, you may need to receive tube feedings. Tube feedings are often started through the J-tube the second day after your surgery. This usually will continue throughout your hospital stay to make sure you have enough nutrition.

What Can I Expect After Discharge? You will be discharged from the hospital when some healing has occurred. Usually a person is able to get enough nutrition, has bowel movements and does not have a fever or signs infection. Each person is a little different when this happens. Most patients can be discharged about 8 – 10 days after the surgery.

minimally invasive esophagogastrectomy, a procedure in which surgeons are given a better view of a patient’s chest and abdomen than that offered by conventional surgery. Endoscopic tools and cameras are inserted through nine small holes in the chest and abdomen during the surgery. Through a two-inch incision in the neck, lymph nodes can be drained and most of the esophagus and one-third of the stomach can be removed without opening the chest and abdomen, or spreading the ribs. After removing the esophagus, stomach and lymphatics, the stomach is then reattached to a pouch at the top of the esophagus. The stretched stomach consumes the space left open by the removed esophagus. In effect, this becomes the patient’s new esophagus.

       Early Results Promising

       Since the incision created during minimally invasive esophagogastrectomy is smaller, patients who have undergone the procedure have had fewer respiratory complications, less pain, and shorter stays in the ICU. the procedure appears to be superior to conventional surgery with regard to postoperative complications and recovery.

 Identifying the Right Candidates

minimally invasive esophagogastrectomy is performed to patients who have localized esophageal cancer that has not metastasized. Patients receiving this new approach should not have had previous chest surgery because scarring can hinder outcomes.

       Even though this is a minimally invasive technique, it is important to remember that these patients are still undergoing a significant operation. Surgeons should encourage patients who are undergoing minimally invasive esophagogastrectomy to walk and talk within a day or two of surgery in order to take advantage of the reduced pain. Within one to two weeks, patients should be able to experience normal swallowing and speech and to eat regular food. Although they cannot have the same large meals as they did before the procedure, good results can be achieved by encouraging patients to eat multiple smaller meals throughout the day.

Diagnosis and prognosis

If cancer is suspected, a thorough examination is conducted to determine its type and stage. The esophagus is visually examined with an endoscope, and tissue samples are taken for biopsy. Several imaging methods are frequently used, such as chest X rays, computed tomography (CT) scans, or ultrasound. There is no definitive laboratory test for esophageal cancer.

Once esophageal cancer has been diagnosed, its stage is determined to indicate how far the cancer has progressed. Stage 0 esophageal cancer is also called carcinoma in situ and is confined to the inner layer of epithelial cells lining the esophagus. Stage I cancers have spread into the connective tissue layer below the epithelium but have not invaded the underlying muscle layer. Stage II cancers either have spread through the muscle layer to the outer boundaries of the esophagus or have spread only into the muscle layer but have reached nearby lymph nodes. Stage III esophageal cancers have spread through the esophageal wall to the lymph nodes or other local tissues. Stage IV cancers have metastasized, or spread, to distant organs such as the stomach, liver, bone, or brain.

The survival rate for esophageal cancer is lower than for many other cancers. When the cancer is detected before it has invaded the underlying tissue layers of the esophagus, five-year survival is high, but fewer than 25 percent of esophageal cancers are diagnosed at this stage. If the cancer has moved to the tissue immediately underlying the

mucosal surface, five-year survival is reduced to about 50 percent, and the rate drops significantly once the cancer has moved from the esophagus to nearby lymph nodes or other tissues. Once the cancer has spread to distant tissues in the body, five-year survival is extremely low.

Treatment

Esophageal cancers are best treated surgically when possible. If the cancer is confined to the upper region of the esophagus, an esophagectomy may be done to remove the cancerous portion, along with nearby lymph nodes, and to reconnect the remaining esophagus to the stomach. For cancers of the lower esophagus, it may be necessary to perform an esophagogastrectomy, in which a portion of the esophagus is removed along with a portion of the stomach. The stomach is then reattached directly to the remaining esophagus, or a segment of the colon is used to link the stomach and esophagus. Both of these surgeries are difficult and often result in serious complications. Other, less-drastic surgeries may be used to relieve symptoms, especially when surgical cure is not possible.

Treatment with radiation alone does not cure esophageal cancer, but it may be used either before surgery to shrink the size of the tumor or following surgery to destroy remaining cancer cells. Radiation therapy is also used to relieve symptoms. The side effects of radiation treatment include vomiting, diarrhea, fatigue, and esophageal irritation. Chemotherapy is also used for some esophageal cancers. It is not curative, but it can relieve some symptoms and may be able to shrink tumours prior to surgery. Side effects resemble those of radiotherapy.

Prevention

Esophageal cancer cannot be completely prevented, but risk can be lowered by reducing alcohol consumption and avoiding tobacco. Individuals who are at high risk should receive regular screening in order to increase the probability of early detection. Because there is no blood test available for esophageal cancer, screening requires regular biopsies and viewing of the esophagus with an endoscope.

Esophageal cancer

Definition

Esophageal cancer is a malignancy that develops in tissues of the hollow, muscular canal (esophagus) along which food and liquid travel from the throat to the stomach.

Description

Esophageal cancer usually originates in the inner layers of the lining of the esophagus and grows outward. In time, the tumor can obstruct the passage of food and liquid, making swallowing painful and difficult. Since most patients are not diagnosed until the late stages of the disease, esophageal cancer is associated with poor quality of life and low survival rates.

Squamous cell carcinoma is the most common type of esophageal cancer, accounting for 95% of all esophageal cancers worldwide. The esophagus is normally lined with thin, flat squamous cells that resemble tiny roof shingles. Squamous cell carcinoma can develop at

any point along the esophagus but is most common in the middle portion.

Adenocarcinoma originates in glandular tissue not normally present in the lining of the esophagus. Before adenocarcinoma can develop, glandular cells must replace a section of squamous cells. This occurs in Barrett's esophagus, a precancerous condition in which chronic acid reflux from the stomach stimulates a transformation in cell type in the lower portion of the esophagus.

A very small fraction of esophageal cancers are melanomas, sarcomas, or lymphomas.

Causes and symptoms

The exact cause of esophageal cancer is unknown, although many investigators believe that chronic irritation of the esophagus is a major culprit. Most of the identified risk factors represent a form of chronic irritation. However, the wide variance in the distribution of esophageal cancer among different demographic groups raises the possibility that genetic factors also play a role.

Diagnosis

A barium swallow is usually the first test performed on a patient whose symptoms suggest esophageal cancer. After the patient swallows a small amount of barium, a series of x rays can highlight any bumps or flat raised areas on the normally smooth surface of the esophageal wall. It can also detect large, irregular areas that narrow the esophagus in patients with advanced cancer, but it cannot provide information about disease that has spread beyond the esophagus. A double contrast study is a barium swallow with air blown into the esophagus to improve the way the barium coats the esophageal lining. Endoscopy is a diagnostic procedure in which a thin lighted tube (endoscope) is passed through the mouth, down the throat, and into the esophagus. Cells that appear abnormal are removed for biopsy. Once a diagnosis of esophageal cancer has been confirmed through biopsy, staging tests are performed to determine whether the disease has spread (metastasized) to tissues or organs near the original tumor or in other parts of the body. These tests may include computed tomography, endoscopic ultrasound, thoracoscopy, laparoscopy, and positron emission tomography.

Treatment

Treatment for esophageal cancer is determined by the stage of the disease and the patient's general health. The most important distinction to make is whether the cancer is curable. If the cancer is in the early stages, cure may be possible. If the cancer is advanced or if the patient will not tolerate major surgery, treatment is usually directed at palliation (relief of symptoms only) instead of cure.

Staging

Stage 0 is the earliest stage of the disease. Cancer cells are confined to the innermost lining of the esophagus. Stage I esophageal cancer has spread slightly deeper, but still has not extended to nearby tissues, lymph nodes, or other organs. In Stage IIA, cancer has invaded the thick, muscular layer of the esophagus that propels food into the stomach and may involve connective tissue covering the outside of the esophagus. In Stage IIB, cancer has spread to lymph nodes near the esophagus and may have invaded deeper layers of esophageal tissue. Stage III esophageal cancer has spread to tissues or lymph nodes near the esophagus or to the trachea (windpipe) or other organs near the esophagus. Stage IV cancer has spread to distant organs like the liver, bones, and brain. Recurrent esophageal cancer is disease that develops in the esophagus or another part of the body after initial treatment.

Surgery

The most common operations for the treatment of esophageal cancer are esophagectomy and esophagogastrectomy. Esophagectomy is the removal of the cancerous part of the esophagus and nearby lymph nodes. This procedure is performed only on patients with very early cancer that has not spread to the stomach. Esophagogastrectomy is the removal of the cancerous part of the esophagus, nearby lymph nodes, and the upper part of the stomach. The resected esophagus is replaced with the stomach or parts of intestine so the patient can swallow. These procedures can significantly relieve symptoms and improve the nutritional status of more than 80% of patients with dysphagia. Although surgery can cure some patients whose disease has not spread beyond the esophagus, but more than 75% of esophageal cancers have spread to other organs before being diagnosed. Less extensive surgical procedures can be used for palliation.

Chemotherapy

Oral or intravenous chemotherapy alone will not cure esophageal cancer, but pre-operative treatments can shrink tumors and increase the probability that cancer can be surgically eradicated. Palliative chemotherapy can relieve symptoms of advanced cancer but will not alter the outcome of the disease.

Radiation

External beam or internal radiation, delivered by machine or implanted near cancer cells inside the body, is only rarely used as the primary form of treatment. Post-operative radiation is sometimes used to kill cancer cells that couldn't be surgically removed. Palliative radiation is effective in relieving dysphagia in patients who cannot be cured. However, radiation is most useful when combined with chemotherapy as either the definitive treatment or preoperative treatment.

Palliation

In addition to surgery, chemotherapy, and radiation, other palliative measures can provide

symptomatic relief. Dilatation of the narrowed portion of the esophagus with soft tubes can provide short-term relief of dysphagia. Placement of a flexible, self-expanding stent within the narrowed portion is also useful in allowing more food intake.

Follow-up treatments

Regular barium swallows and other imaging studies are necessary to detect recurrence or spread of disease or new tumor development.

Alternative treatment

Photodynamic therapy (PDT) involves intravenously injecting a drug that is absorbed by cancer cells and kills them after they are exposed to specific laser beams. PDT can be used for palliation, but it also cured some early esophageal cancers during preliminary studies. Researchers are comparing its benefits with those of more established therapies.

Endoscopic laser therapy involves delivering short, powerful laser treatments to the tumor through an endoscope. It can improve dysphagia, but multiple treatments are required, and the benefit is seldom long-lasting.

Prognosis

Since most patients are diagnosed when the cancer has spread to lymph nodes or other structures, the prognosis for esophageal cancer is poor. Generally, no more than half of all patients are candidates for curative treatment. Even if cure is attempted, the cancer can recur.

Prevention

There is no known way to prevent esophageal cancer.

Computed tomography A radiology test by which images of cross-sectional planes of the body are obtained.

Endoscopic ultrasound A radiology test utilizing high frequency sound waves, conducted via an endoscope.

Laparoscopy Examination of the contents of the abdomen through a thin, lighted tube passed through a small incision.

Positron emission tomography A radiology test by which images of cross-sectional planes of the body are obtained, utilizing the properties of the positron. The positron is a subatomic particle of equal mass to the electron, but of opposite charge.

Synergistic

The combined action of two or more processes is greater than the sum of each acting separately.

Thoracoscopy Examination of the contents of the chest through a thin, lighted tube passed through a small incision.

Symptoms

It's unusual to have signs and symptoms of esophageal cancer in the early stages of the disease. When the disease is more advanced, esophageal cancer symptoms may include:

Difficulty swallowing (dysphagia). Although this is the most common symptom of esophageal cancer, it usually doesn't appear until a tumor has grown large enough to narrow your esophagus to about half its normal width. At this point, meat and bread may be nearly impossible to swallow, and you may unconsciously change your eating habits, chewing more thoroughly and carefully, or switching to softer foods. In time, even liquids may be hard to swallow.

Unintentional weight loss. As eating becomes more difficult, you may not consume enough calories to maintain your weight. In addition, cancer in general can cause weight loss and muscle wasting because it changes the way your body metabolizes nutrients.

Pain in your throat, in your midchest or between your shoulder blades. Although not common, you sometimes might have pain when you swallow or discomfort or burning behind your breastbone.

Hoarseness, hiccups and sometimes vomiting of blood. These signs and symptoms usually don't appear until cancer is quite advanced.

Cause

Cancer can occur almost anywhere along the length of the esophagus and is classified according to the types of cells in which it originates:

Squamous cell or epidermoid carcinoma Adenocarcinoma. Others

Contributing factors

Healthy cells grow and divide in an orderly way. This process is controlled by DNA — the genetic material that contains the instructions for every chemical process in your body. When DNA is damaged, changes occur in these instructions. One result is that cells may begin to grow out of control and eventually form a tumor — a mass of malignant cells.

Although researchers don't know all the causes of esophageal cancer, they have identified several factors that can damage DNA in your esophagus. These factors include:

Heavy alcohol consumption. many of esophageal squamous cell carcinomas result from chronic alcohol abuse. Long-term heavy drinking irritates the lining of the esophagus, leading to inflammation that eventually may cause malignant changes in the cells.

Tobacco use. Using tobacco in any form, including cigarettes, cigars, pipes and chewing tobacco, increases your likelihood of developing esophageal squamous cell carcinoma. The risk increases with long-term use and rises even more for people who both smoke and drink.

Chronic acid reflux. Sometimes the lower esophageal sphincter relaxes abnormally or weakens, allowing caustic stomach acids to back up into your esophagus (esophageal reflux). The result is heartburn — a burning chest discomfort that in severe cases may mimic the symptoms of a heart attack.

Occasional heartburn usually isn't serious, but chronic acid reflux can lead to Barrett's esophagus, a condition in which cells similar to your stomach's glandular cells develop in the lower esophagus. These new cells are resistant to stomach acid, but they also have a high potential for malignancy. Gastroesophageal reflux is the cause of about one-third of esophageal cancers. Smoking, obesity and a high-sodium diet put you at increased risk of reflux problems.

Diet. Eating a diet low in fruits and vegetables appears to contribute to esophageal cancer. Especially implicated are diets lacking in vitamins A, C and B-1 (riboflavin). People with low levels of the mineral selenium have a higher risk of esophageal cancer than do people with normal blood-selenium levels. Because high doses of selenium can be toxic, experts recommend getting selenium from foods such as fish, whole-grain bread, Brazil nuts and walnuts rather than from supplements.

Obesity. Weighing significantly more than your ideal weight — having a body mass index greater than 25 — has been linked to an increased risk of adenocarcinoma.

Sometimes esophageal cancer is associated with certain rare medical conditions, including:

Achalasia. In this disorder, food collects at the bottom of the esophagus, both because the esophagus lacks normal peristalsis to move food along and because the lower esophageal sphincter doesn't relax normally. For reasons that aren't clear, having achalasia seems to increase your risk of esophageal cancer.

Esophageal webs. These thin protrusions of tissue can appear anywhere in your esophagus. Some webs cause no symptoms, but others can make swallowing difficult. When other problems — including anemia and abnormalities of the tongue, fingernails and spleen — occur in conjunction with esophageal webs, the

condition is called Plummer-Vinson or Paterson-Kelly syndrome. People with this syndrome are at risk of developing esophageal cancer.

Tylosis. Excess skin develops on the soles and palms of people with tylosis, a rare inherited disorder. Close to half the people with tylosis eventually develop esophageal cancer. A genetic defect appears to be responsible for both tylosis and the associated

Risk factors

Other factors that may increase your chances of developing esophageal cancer include:

Age. Your risk of developing esophageal cancer increases as you grow older. Most people with the disease are between 55 and 70. The risk is much less if you're younger than 40.

Sex. Men are far more likely to develop esophageal cancer than women are. Radiation therapy. People who've had radiation treatment to treat cancers near

the esophagus have a higher risk of esophageal cancer. Occupational exposure. People who work with dry cleaning solvents appear to

have an increased risk of esophageal cancer, as do people exposed to silica dust — a primary component of sandstone and granite. Miners, people working in the pressurized spaces used in building tunnels, and construction workers, especially those handling brick, concrete or tile, are likely to be exposed to high levels of silica dust.

Drinking hot liquids. There's some evidence that people who frequently consume very hot beverages have an increased risk of squamous cell esophageal cancer.

Tests and diagnosis

To help find the cause of your symptoms, your doctor will take a complete medical history and perform a physical exam. You're also likely to have a chest X-ray and other diagnostic tests, such as:

Barium swallow (esophagram). A diagnostic test often given to people who have difficulty swallowing, a barium swallow uses a series of X-rays to examine your esophagus. During the test, you'll drink a thick liquid (barium) that temporarily coats the lining of your esophagus so that the lining shows up clearly on the X-rays. You may also have air blown into your esophagus, to help push the barium against the esophageal walls. Although a barium swallow can help diagnose cancer, it may not show whether a tumor has spread beyond your esophagus. After the test you can eat normally and resume your daily activities, although you'll need to drink extra water to help flush the barium from your system and prevent constipation.

A barium swallow briefly exposes you to ionizing radiation. Although the danger from this exposure is small, care is taken to produce the best images with the lowest amount of radiation and the fewest possible X-rays.

Esophagoscopy (upper endoscopy). During this procedure, your doctor examines the inside of your esophagus using an endoscope — a thin, lighted tube with a tiny camera on the end that sends images to a TV monitor. Your throat will likely be sprayed with a topical anesthetic before you're asked to swallow the tube, and you may also receive medication through your veins (intravenously) to make you more relaxed and comfortable.

The endoscope allows your doctor to clearly see any masses in the esophageal wall as well as to take a tissue sample (biopsy) of any abnormalities. The samples are then sent to a laboratory for analysis. This test also allows your doctor to determine if you have Barrett's esophagus and need to be treated for this condition, as well as if you need to be screened at more frequent intervals in the future.

Risks of the procedure include a reaction to the medication and bleeding at a biopsy site. If your doctor needs to make a wider opening in your esophagus because of a stricture or narrowing, there's a small risk of creating a hole in your esophagus (esophageal perforation) during the dilation procedure.

Screening tests

Screening tests check for a disease in its early stages, before you develop symptoms. If you're at high risk of esophageal cancer, especially if you have Barrett's esophagus or tylosis, you're likely to have regular endoscopic examinations and biopsies. If you have cell abnormalities (dysplasia), experts recommend testing at least once a year.

Staging tests

If cancer is diagnosed, you're likely to have more tests to determine whether and where the cancer has spread (metastasized), a process known as staging. This step is especially important because it helps your doctor determine the most appropriate treatment. Esophageal cancers are staged using the numbers 0 through IV. In general, the higher the number the more advanced the cancer.

Stage 0. These cancers — also called noninvasive cancer, high-grade dysplasia or carcinoma in situ, meaning in one place — haven't spread to other parts of your body. Still, it's important to have them followed closely or removed because they eventually may become invasive.

Stage I. This cancer occurs only in the top layer of cells lining your esophagus.

Stage II. At this stage, the cancer has invaded deeper layers of your esophagus lining and may have also spread to nearby lymph nodes.

Stage III. The cancer has spread even more deeply into the wall of your esophagus and to nearby tissues or lymph nodes.

Stage IV. At this stage, the cancer has spread to other parts of your body.

To help stage esophageal cancer, you may have one or more of these tests:

Bronchoscopy. In this procedure, which is similar to esophagoscopy, your doctor uses an endoscope to examine your windpipe (trachea) and the air passages leading to your lungs (bronchi) to determine whether cancer has spread to these areas.

Computerized tomography (CT) scan. This X-ray technique produces more-detailed images of your internal organs than do conventional X-ray studies. That's because a computer translates information from X-rays into images of thin sections (slices) of your body at different levels. CT scans can confirm the location of a tumor within the esophagus and whether cancer has spread to nearby lymph nodes or other organs. A CT scan exposes you to more ionizing radiation than plain X-rays do and usually isn't recommended if you're pregnant.

Endoscopic ultrasound. This procedure may prove to be more accurate than either CT scans or upper endoscopy in determining how far an esophageal cancer has spread into nearby tissues. During the test, a tiny ultrasound probe is passed through an endoscope into your esophagus. The probe produces very sensitive sound waves that penetrate deep into tissues. A computer then translates the sound waves into close-up images of your esophagus and nearby tissues. Your doctor can also take biopsies of lymph nodes and other tissues during the procedure. Endoscopic ultrasound uses sound waves rather than X-rays to create images, and the risks of the procedure, such as bleeding or perforation of the esophagus, are slight.

Positron emission tomography (PET) scan. During this test, your doctor injects a small amount of a radioactive tracer — typically a form of glucose — into your body. All tissues in your body absorb some of this tracer, but tumors absorb greater amounts and appear brighter on the scan than healthy tissue does. A PET scan exposes you to a small amount of radiation, but because the radioactivity is short-lived, your overall exposure is low.

Complications Tracheoesophageal fistula. This occurs when a tumor creates a hole between

your esophagus and windpipe, leading to coughing and gagging when you swallow. A tracheoesophageal fistula requires surgery or the use of a stent to prevent food or liquid from your esophagus entering your windpipe and lungs.

Severe, unintended weight loss. About half the people with esophageal cancer experience severe weight loss and weakness, usually because of cancer-caused changes in metabolism or because swallowing is painful and difficult.

Metastasis. This is the most serious complication of esophageal cancer. Because esophageal tumors are rarely discovered in the early stages, they often have

spread to nearby lymph nodes or to other parts of your body, such as the lungs or liver, before they're diagnosed.

Treatments and drugs

Esophageal cancer treatment depends on the type, location and stage of cancer as well as on your age, overall health and personal preferences. Decisions about therapy can be particularly complicated because various combinations of surgery, chemotherapy and radiation may be more effective than any single treatment First and foremost, the goal of treatment is to eliminate the cancer completely. When that isn't possible, the focus may be on preventing the tumor from growing or causing more harm. In some cases, an approach called palliative care may be best. Palliative care refers to treatment aimed not at removing or slowing the disease, but at helping relieve symptoms and making you as comfortable as possible.

Surgical options

Surgery is a common treatment for esophageal cancer, either as a therapy for the cancer itself or as a way to relieve symptoms, especially difficult swallowing. Depending on the nature of the cancer, the operation may be performed in one of two ways:

Esophagectomy. Doctors generally recommend this approach for early-stage esophageal cancer that doesn't involve your stomach. During the procedure, your surgeon removes the portion of your esophagus that contains the tumor along with nearby lymph nodes. The remaining esophagus is reconnected to your stomach. In some cases the stomach is pulled up to the esophagus. In others, part of your large intestine is used to replace the missing section of your esophagus.

Esophagogastrectomy. In this procedure, which is used for more advanced cancer, your surgeon removes part of your esophagus, nearby lymph nodes and the upper part of your stomach. The remainder of your stomach is then pulled up and reattached to your esophagus. If necessary, part of your colon is used to help join the two.

Surgery for esophageal cancer is complex and carries risks that include infection, bleeding and leakage from the area where the remaining esophagus is reattached. Hospitals where surgeons perform a large number of esophagectomies have significantly lower mortality rates than do hospitals where few esophagectomies are performed. If you're considering this surgery, look for a hospital or medical center whose surgeons are highly experienced in the procedure.

ChemotherapyUsing drugs to kill cancer cells is another option for treating esophageal cancer. Chemotherapy medications, which can be injected into a vein or taken by mouth, travel throughout your body, attacking cancer cells in and beyond your esophagus. You usually

receive a combination of anti-cancer drugs given in cycles, with periods of recovery alternating with periods of treatment.

Chemotherapy can help in several ways — before surgery to shrink the tumor, in combination with radiation when surgery isn't an option, or to relieve symptoms in advanced cases of esophageal cancer.

Unfortunately, anti-cancer drugs affect normal cells as well as malignant ones, especially fast-growing cells in your digestive tract and bone marrow. For that reason, side effects — including nausea and vomiting, mouth sores, an increased chance of infection due to a shortage of white blood cells, and fatigue — are common. Not everyone experiences side effects, however, and there are now better ways to control them if you do. Be sure to discuss any questions you may have about side effects with your treatment team.

Chemotherapy may also be given at the same time as radiation treatment. Certain chemotherapy drugs can make the radiation treatments more effective, but this also may increase some of the side effects.

Radiation therapyRadiation is used as a primary treatment for esophageal cancer, in combination with chemotherapy or to shrink a tumor before surgery. It's also used to relieve pain and improve swallowing. Most often, the radiation comes from a machine outside your body (external beam radiation), but sometimes thin plastic tubes containing radioactive material are implanted near the cancer cells in your esophagus (brachytherapy).

The most common side effects are fatigue — which generally becomes more noticeable later in the course of treatment — skin rash or redness in the area being treated, loss of appetite, and sores in the esophagus that cause problems with swallowing. (2) In fact, swallowing may become so difficult that your doctor will recommend a feeding tube to provide nourishment during treatment.

These side effects generally aren't permanent, and most can be treated or controlled. Long-term side effects are rare, but they can be serious when they do occur and include inflammation or scarring in the lungs.

Photodynamic therapyThis therapy is generally used to relieve pain and obstruction in the esophagus, but it's also being studied as a treatment for early-stage esophageal cancer. During the procedure, you receive an injection of a light-sensitive drug that remains in cancer cells longer than it does in healthy ones. A laser light is then directed at your esophagus through an endoscope. This stimulates the production of an active form of oxygen that destroys the cancer cells while sparing healthy tissue.

Photodynamic therapy isn't without side effects. It makes your skin and eyes sensitive to light for at least six weeks after treatment, so you'll need to wear protective clothing and sunglasses every time you go outdoors.

Areas of researchScientists are continually seeking more effective and less harmful treatments for esophageal cancer. Some areas of research include:

Gene therapy.Researchers have identified many of the genetic changes that cause healthy esophageal cells to become malignant. Understanding these changes may eventually lead to gene therapies that help repair abnormal DNA.

Chemotherapy. Scientists are studying a range of chemotherapy options, including new anti-cancer drugs such as tyrosine kinase inhibitors. Protein-tyrosine kinases are substances that help regulate signals in cells, especially regulating cell growth and the ability of cells to die. Blocking these abnormal signals from protein-tyrosine kinases can kill the cancer cells, and many researchers are focused on finding new ways to selectively inhibit these signals. Also under investigation are new combinations of existing drugs and different combinations of radiation and chemotherapy.

Immunotherapy. This therapy stimulates your immune system to fight cancer. One approach uses monoclonal antibodies, which are produced by fusing antibody-forming cells and tumor cells, to treat esophageal adenocarcinomas.

Clinical trialsIf you have advanced esophageal cancer, you may want to consider participating in a clinical trial. This is a study that's used to test new forms of therapy — typically new drugs, different approaches to surgery or radiation treatments, and novel methods such as photodynamic therapy. If the therapy being tested proves to be safer or more effective than current treatments, it will become the new standard of care.

The treatments used in clinical trials haven't yet been shown to be effective. They may have serious or unexpected side effects, and there's no guarantee you'll benefit from them.

On the other hand, cancer clinical trials are closely monitored by the federal government to ensure they're conducted as safely as possible. And they offer access to treatments that wouldn't otherwise be available t

Prevention

Although it's not possible to prevent all cases of esophageal cancer, the following lifestyle changes can greatly reduce your risk:

Quit smoking. This may be the single most important thing you can do to prevent esophageal cancer and improve your overall health. Cigarette smoke contains carcinogens that can damage the DNA that regulates cell growth and is a leading cause of gastroesophageal reflux. Talk to your doctor about the best ways to quit, or contact the American Cancer Society for more information.

Limit alcohol consumption. Many esophageal squamous cell carcinomas and adenocarcinomas result from heavy alcohol consumption over a period of years. Abstaining from alcohol or drinking in moderation — no more than one drink

daily for women or two drinks daily for men — can greatly reduce your risk of this type of esophageal cancer.

Get help for heartburn. Don't ignore severe or frequent heartburn. Your doctor can recommend medications and lifestyle changes that can help prevent gastric reflux. Sometimes drugs that inhibit acid formation may provide the relief you need. You may also be helped by waiting at least two to three hours after eating before lying down or exercising, and by elevating the head of your bed.

Eat a healthy diet. Eating more fruits and vegetables may help protect against esophageal cancer. Aim for at least five fruits and vegetables daily. Choose whole-grain foods over processed or refined grain products. Limit the amount of red meat and processed meats that you consume.

Maintain a healthy weight. Being significantly overweight (obese) increases your risk of esophageal cancer as well as your risk of other serious health problems, such as diabetes, cardiovascular disease and stroke. Slow and steady weight loss of 1 or 2 pounds a week is considered the safest way to lose weight and keep it off. In many cases, you can lose weight by committing to eating a healthier diet, exercising and changing unhealthy behaviors.