MIS (Minimally Invasive Surgery) for nasopharyngeal cancer and reconstruction

by Dr. G. C. Liu and Dr. Jason Shih

What type of nasophageal cancer would receive the optimal benefit from surgical resection and thoracic reconstruction?

According to the esophageal cancer treatment guidelines developed through the collaborative efforts of our treatment teams, patients in the early stage (tumor <3cm and no evidence of lymph node involvement on PET scan) and those aged 65 or younger in stage II or III, who will be given CCRT (concurrent chemo-radiation therapy), should consider curative esophagectomy which surgically removes the lower two-thirds of the esophagus, and all of the surrounding lymph nodes, followed by the reconstruction of the esophagus by reshaping the stomach into a “new esophagus,” which is then brought up into the chest or the neck to be reconnected to the remaining portion of the esophagus.

The above-mentioned treatment involves open surgical repair of a large area in the neck, chest and abdomen, and could last up to 9 hours.  The recovery time is understandably longer with monitoring in the ICU.  Esophageal cancer has symptoms that are usually not noticed until the disease is locally advanced with a high incidence rate of lymph node mets accompanied with vascular, airway and/or neural invasions.   Our clinical experience, echoed by guidelines from major hospitals worldwide, indicates that the curative esophagectomy combined with CCRT could best achieve optimal clinical results. 

Risks and success rates: 

Esophagectomy is considered  the most effective treatment for esophageal cancer to date.  Serious nutrition issues due to post-treatment swallowing difficulties, large surgical area, and the long operation hours are all reasons why patients have to be transferred to the ICU for close monitoring and management.   Reports from sizable hospitals,domestical and overseas, have shown a mortality rate of 5-10% from the time after surgery to the time of discharge.  There is also a 50/50 chance of post-surgery complications.  The 5-year survival  rate with treatment is 20 – 30%.  Our record, from year 2000 to the present, shows a <1% of mortality rate  from esophageal surgery, and our 5-year survival is 47%.   We have a 65% complication rate because most patients receive pre-surgery CCRT.  We have started to employ the minimally invasive technique for our nasopharyngeal surgeries.  So far the data shows smaller surgical wounds, reduced pain, and faster healing, with a 3-year survival that is slightly better than that from open surgery.

Possible post-surgery complications include:

1.     Fever caused from the patient’s inability to take deep breaths or    clear the phlegm

2.     Fever or difficulty breathing caused by build-up of phlegm or by obstruction in bronchia

3.     Further surgical drainage due to pleural effusion or maturation

4.     Pneumonitis, fever, respiratory failure

5.     Prolonged eating time or more procedures due to poor healing of the sutures at the esophagus and stomach

6.     Hoarseness , inability to cough up phlegm, tendency to choke easily, or even aspiration pneumonia that is related to nerve injury during the surgery or anesthesia

7.     Temporary Arrhythmia, pulmonary edema, or pulmonary

8.     Infection or inflammation of the wounds that may lead to septicemia  or multiple organ failure  and even death

9.     Acid reflux

10.   Delayed gastric emptying or cholestasis in the future due to loss of vagus nerve during the esophagectomy

When a patient refuses surgical intervention, some possible consequences include recurrence or enlargement of the tumor which may cause obstruction, swallowing difficulty, bleeding or even rupture of the esophagus; any distant metastasis or organ invastion may lead to narrowing of the airway, hemoptysis, discomfort and pain from the mets, or even death.  Please bear in mind there are risks and hazards associated with the surgeries as well. 

Depending on the different treatment needs or limitations, other treatment options for nasopharyngeal cancer include:

1.     CCRT – concurrent chemoradiation therapy

2.     Radiotherapy alone

3.     Chemotherapy alone

4.     Esophageal stenting

5.     Photodynamic therapy 

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