【外科学习】_8.食管癌的外科治疗.pptVIP

食管切除 经食管裂孔 经腹部及右胸（IVOR-LEWIS) 经左胸 经腹部右胸在左颈部吻合 腹腔镜+胸腔镜（hybrid) 机器人手术 经裂孔食管癌切除 拔脱器 置入拔脱器 拔脱食管 经腹部经右胸食管癌切除，胸内吻合(IVOR-LEWIS) but, CT chest and abdomen -- only 60% accurate in detecting regional lymph node disease but, CT chest and abdomen -- underestimates tumor stage in 40% of patients Endoscopic ultrasound -- incorrect in determining wall depth 15-20% of the time Endoscopic ultrasound -- incorrect in determining nodal status 25 - 30% of the time Endoscopic ultrasound -- less accurate after neoadjuvant therapy * ?stage I disease—particularly Tis and T1aN0 by endoscopic ultrasonography (EUS)—may be considered for endoscopic therapy, such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) * PET-CT for initial staging is considered to be a valuable tool for the detection of additional metastases and is also used for radiotherapy planning. Despite limited published evidence, induction chemotherapy is often being implemented. Improvement of dysphagia, quick start of therapy and control of systemic disease are the most prominent reasons for this strategy. 41.4–45 Gy are considered adequate in the neoadjuvant setting. The dose for definitive CRT is much more controversial, the opinions range from 50.4 Gy to over 60 Gy. After neoadjuvant CRT, restaging with CT scan is sufficient, some countries repeat endoscopy. PET-CT is not part of standard preoperative restaging so far. Most agreed on transhiatal resection for Siewert II tumours and transthoracal approach for Siewert I tumours (transthoracical en-bloc esophagectomy). Despite limited follow-up and high requirements in expertise, in most centres, minimally invasive surgery is considered an option, several studies are ongoing. Squamous cell cancer ○ Most countries prefer definitive CRT for SCC located in the upper thoracic oesophagus ○ Reasons preferring definitive CRT over surgery independent of the location: patient preference, co-morbidities, high biological age and h