Mount Sinai Chief of Thoracic Surgery, Dr. Raja Flores, MD talks about a new technique to lessen symptoms of esophageal cancer.
Interview conducted by Ivanhoe Broadcast News in 2022.
Can you tell me about some of the symptoms of esophageal cancer?
FLORES: The biggest thing with esophageal cancer, by the time you’re having trouble swallowing, it shows that the tumor has advanced decent amount. The biggest way you can anticipate this is when you have a lot of reflux, when you have heartburn, when you feel like there is burning in your chest that’s going up here and then you have this sour taste in your mouth. That’s the reflux. That leads to a chronic irritation of the inner wall of the esophagus, the mucosa, and that leads to certain changes that then become esophageal cancer. So you don’t want to wait until you can’t really swallow. Once you’re feeling that reflux, you want to see your doctor and make sure that they either treat it with some medication or that eventually you get a scope where they go down and they just take a look in there. It’s a quick procedure. It’s not surgery where you need to get cut or anything, and it can save your life.
How common is it and is it one of those cancers where we’re seeing more cases?
FLORES: Esophageal cancer is not one of the more common ones. There are about 19-20,000 cases a year in the United States, but it’s one of the more deadly cancers. It presents at a later stage because by the time you get symptoms, usually, it had already spread somewhere else. But when caught early, it’s very curable. In Stage 1, it’s very curable.
What are the treatments?
FLORES: The biggest treatment with esophageal cancer is to get it out just like with every other cancer. You catch it early, you get it out, you have a better chance of being cured with a smaller operation. Once it gets to a bigger size, you need a bigger operation and you have less of a chance of cure. That’s why, with any cancer, especially esophageal cancer, it’s important to get it early.
Is chemo also a treatment?
FLORES: You also have a combination of chemotherapy and radiation. When you’re a little more advanced, when we call, like a Stage 3, usually, those patients get chemotherapy and radiation, then they heal in the next few weeks, and then they get their surgery. So, it’s a combination of chemo radiation and then surgery. Now, you also have immunotherapy. So basically, you’re hitting it with the kitchen sink.
Now, your surgical procedure, I understand that you do some additional things or unique things that have increased not only the speed, but I guess the success rate of the surgery. Can you explain that?
FLORES: The biggest thing with esophageal surgery, esophagectomy, is that it is filled with complications. What you want to make sure of is that you can have a low, weak rate, weak where you take your esophagus and you bring your stomach together. We have to bring that together physically with either sutures are staples. And that needs to heal. And when that doesn’t heal, the contents leak out. We remove the cancer with the esophagus with all the cancer in it, then we take the stomach and the residual esophagus and bring it together in. And esophageal leak is the most morbid complication producing adverse effect that you can get from esophagectomy. So naturally, you want to minimize that leak. And because of years of experience, not just my own, but all of our experiences here from other surgeons and other institutions, we’ve developed a way of doing this esophagectomy with one of the lowest leak rates ever reported. So our leak rate, which we just published in the literature is 1.8 percent, which is phenomenal compared to many places that have leak rates of 20 percent and 25 percent. So, we can do this operation in a way where you’re leak rate is one or two for every 100 patients and that really benefits these patients.
If you have a higher leak rate, what happens? Do you have to go back in for surgery?
FLORES: A leak can be self-contained where it just takes a week or two to get better. A leak can be out of control where the patient is sick. Sepsis can potentially lead to death. A leak rate can have consequences like a stricture where then you can’t really eat and you have to dilate it, where you have other complications, where you have to have a reoperation, where it can fistulas into other things like your trachea and to other structures that are in your chest. So you want to minimize that leak as much as possible. And we have figured out a way that we do a quick operation in less than three hours usually where the leak rate is incredibly low, like I said, 1.8 percent. And these patients have a high success rate with regard to the cancer. We also know from studies that patients with a higher leak rate have a higher recurrence rate of cancer. So the more that you can minimize a complication, like a leak, especially a week, then your chances of doing well, not just in the short term, but in the long term will be better.
Can you explain how you’re able to do this in a way that improves the leak rate and also shortens the surgical?
FLORES: The surgical principles are actually very simple. The main thing whenever you bring two things together in your body is do they have a good blood supply? And it’s that simple. It’s not like it’s rocket science. So there’s certain vessels, the right gastroepiploic artery, the right gastric artery that we’ve routinely preserve. Many people think you just preserve the right gastroepiploic artery. Now, the right gastric artery is a small artery that many people don’t even think you need to preserve it. But we firmly believe in that. In my experience in the past, whenever we take that right gastric artery, that patient had a leak. So I said, well, why are we taking this? And we figured out that you can do the operation without removing without cutting that right gastric artery. And it’s not just the artery, but it’s the artery, the vein. You want to make sure you keep everything intact so that when you cut that area, it’s bleeding. Bleeding means that you are going to heal. And so we bring them together in a way where they have a good blood supply, where it’s not a lot of tension which pulls it apart, and where we make sure that each stitch and each surgical clip that we use bring the two ends together perfectly. And that leads to that low leak rate. And that’s the whole game when it comes to esophagus.
Can you talk about your patient, Mr. Lou Martinez?
FLORES: Mr. Martinez was no different than any other patient, scared, confused. You think the worst once you hear, the big “C” word (cancer), you automatically think, I’m going to die. Cancer does not equal death. When you hear about an esophagectomy and you look it up on the internet, you see all these horrible complications. And it doesn’t have to be that way. We’ve tried to disseminate or a technique all over so that other people can learn how to do it. It’s on the internet, something called CTSNet where surgeons can learn from it. We just published it. There’s a way to do this operation where you don’t have to have a ton of complications. And so Mr. Martinez was concerned, Number 1, that he had cancer, Number 2, that he had to undergo this big operation. And so we counseled him a couple of times. I will never operate on somebody unless they know 100 percent they’re all in. I mean, I’ve cancer canceled many patients in the waiting area because I didn’t get a sense that they were ready for it. Then he was ready. And the biggest thing that I think helped him was letting him speak to some of my other patients. Once you hear that somebody else has walked the walk that you need to go through. It makes it somewhat more palatable for you. And I think after he spoke to some of my patients, he said, I’m going to do it. And he did great. I don’t think he had any complications and he went right through. He did well.
What is the name of the procedure?
FLORES: Ivor Lewis esophagectomy.
Why those two names?
FLORES: That’s one name. It’s the name of the guy that invented it, and I think in like 1940. When he did that, there were a lot of inherent deficiency in that that we improved upon. So not only the blood supply, but where we plug it in. So usually, they would plug it in on the tip of the stomach. And the tip of the stomach has the weakest blood supply. What we do is we plug it in the body of the stomach where the blood supply is just really rich. And that helps it to heal without a leak.
END OF INTERVIEW
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