Swallowing function after esophagectomy for esophageal cancer

Abstract

Swallowing difficulty is a common symptom at diagnosis of esophageal cancer. Esophagectomy is the mainstay treatment and alleviates dysphagia through removal of the obstructing tumour. A transient oropharyngeal dysphagia often follows esophagectomy and aspiration pneumonia has been reported long after esophagectomy. This may reflect residual swallowing deficits, which have not previously been studied. This thesis investigates this issue in depth.

Swallowing-related (SR) quality of life (QOL) has not previously been investigated in patients long-term after esophagectomy. Twenty-nine post-esophagectomy patients who were more than six months postoperative were assessed using validated SR, general and esophageal cancer-specific QOL questionnaires. Reductions in SR QOL were apparent, yet general QOL was similar to the general population. This suggests continued swallowing issues late after esophagectomy and that more focus should be placed on swallowing at this stage.

Oropharyngeal swallowing function in long-term post-esophagectomy patients was also investigated using videofluoroscopic swallow studies (VFSS). Twenty-nine long-term post-esophagectomy patients underwent VFSS. Dysphagia predominantly affected the pharyngeal phase of swallowing and was of mild to moderate severity. Dysphagia was more severe in males, and those of advanced age at esophagectomy and swallowing assessment. Higher pN stage and less time from esophagectomy were associated with worse penetration and aspiration. These findings pave the way for more effective swallowing rehabilitation and have implications on prioritization of patients for early swallowing assessment and therapy.

High-resolution manometry (HRM) was also used to examine swallowing in this population. The objective measures of pharyngeal and esophageal HRM supplement VFSS findings and improve understanding of the biomechanics of the dysphagia. Twenty-nine long-term post-esophagectomy patients underwent pharyngeal and esophageal HRM. All measured pressures differed from norms except for velopharyngeal maximum pressure. Average maximum pressures in the residual cervical esophagus were higher than norms and gastric conduit pressures were negligible. The pharyngeal swallow pressure events in this population have not been studied before. Also, this is the first in depth analysis of the residual cervical esophagus and gastric conduit using HRM. Abnormalities may reflect unresolved damage to the pharyngeal plexus, or alterations made to compensate for changes to the esophagus.

More studies are needed to improve our understanding of the clinical relevance of pharyngeal HRM measures. Twenty-nine long-term post-esophagectomy patients underwent VFSS and HRM. The HRM correlates to VFSS findings were studied. There were significant HRM predictors for the VFSS findings: premature spillage, presence of pyriform sinus residue, penetration and aspiration. Clinical utility of this information, such as the use of HRM to differentiate between premature spillage and delayed swallow trigger, is discussed. Differences in the swallowing biomechanics of aspiration events between high and low viscosity substances are also discussed.

Two patients with oropharyngeal dysphagia early post-esophagectomy who underwent six weeks of swallowing therapy are presented. Definitive improvements were seen on VFSS. Changes on HRM measures were seen, but interpretation of these changes requires further research. The HRM-VFSS predictive model introduced in a previous chapter is applied. Further research regarding the behaviour of contact pressures measured on HRM in relation to changes in swallowing function is needed. [499 words]