Overview
Esophagectomy is the partial or complete surgical removal of the esophagus. It is most often performed to remove esophageal cancer or benign lesions. In cases involving cancer (adenocarcinoma, typically, and sarcoma), the procedure is recommended when the disease is thought to be contained to the esophagus and not found to have metastasized. Often the procedure follows courses of chemotherapy and radiation, which might also be continued postoperatively.
Esophagectomy also may be appropriate for patients who have
Barrett’s esophagus, a tissue-metamorphosis associated with chronic gastroesophageal reflux (
GERD) that has developed into cancer, or pre-cancerous changes called high-grade dysplasia. People whose esophagus has been injured by ingestion of caustic substances also are candidates for esophagectomy, as are people with [achalasia] – poor motility of food from the throat to the stomach.
For decades, surgeons have approached this procedure via open thoracotomy, a large incision in the chest. Today surgeons can approach laparoscopically, manipulating their instruments through a series of tiny incisions in the patient’s upper abdomen while viewing with a tube-based camera inserted in the patient. Surgeons must have advanced skills for laparoscopic surgery. Patients also are carefully evaluated to determine whether they are sufficiently healthy to undergo surgery.
Via open or laparoscopic approach, this surgery and anesthetization is complex because of the anatomical structures involved. Depending on the length of esophagus to be removed, surgeons may reshape the stomach into more of a tube and move it up into an esophageal position. Alternately, a segment of large intestine may be used instead. Surgeons might need to make additional incisions at the chest or neck to sufficiently access the structures involved.
Patients spend a week or more in the hospital after surgery. In some cases, recovery can take up to six months. Postoperative complications emerge in up to 30 percent of patients – though they may be minor.
Patients should expect to change dietary habits after surgery, eating smaller portions of soft foods and avoiding high-fat and spicy dishes, and not taking liquids with meals. Many patients find it easier to puree meals. Patients often find it helpful to eat more slowly and to stand or sit upright for a few hours after meals to minimize reflux and regurgitation
Procedural Details
Before surgery, the patient will be on a restricted diet for several days. On the day of surgery, the patient will be sedated and given a general anesthetic. Barring complications, the esophagectomy takes about six hours, on average.
Operating laparoscopically, the surgeon makes five small incisions in the patient’s upper abdomen, through which he manipulates instruments. The surgery has several stages, typically working from the lower structures (the stomach) to the esophagus. If the stomach is to replace the esophagus, the stomach is divided, with some tissue removed and the remainder reshaped and sutured to create a more tubular structure. The diseased or damaged esophagus is then removed and the stomach connected to the remaining upper esophagus.
Removal of the lower esophagus might involve the lower esophageal sphincter (LES), which acts as a valve to keep stomach acids from reaching the esophagus. Therefore, many patients experience some reflux symptoms and may require medications and changes to dietary habits can help minimize the effects of reflux.
Post-operative hospitalization typically is one to two weeks, depending on the surgeon’s approach; but usually with laparoscopy typically results in faster recovery than open (6-8 days). Recovery in hospital might take longer if complications ensue. Feeding tubes might be inserted during surgery temporarily to provide a nutrition until oral eating is resumed.
Medications
Post-operative medications typically include narcotics for pain relief. Patients might be prescribed medication to control nausea and reduce the stomach’s production of acid
Considerations
Esophagectomy is appropriate for patients who have benign or cancerous lesions that cannot be addressed by endoscopic ablation or resection, or who have failed nonsurgical therapies or whose esophagus is at high risk of perforation. Esophagectomy is the most reliable treatment for removing cancerous and potentially cancerous tissue segments.
In the absence of surgery, esophageal cancer is difficult to treat successfully – five-year patient-survival rates range from 5 percent to 30 percent. Patients with cancer diagnoses should seriously consider a physician’s recommendation of esophagectomy as life-extending and potentially life-saving. However, cancer found to have metastasized to adjacent structures, such as the trachea, contraindicates surgery due to poor prognosis for patients.
One contributing factor might be the exposure of the remaining esophagus to refluxed acids produced by the more proximal stomach. Repeated acid contact with the remaining esophageal tissue can lead to Barrett’s esophagus, a condition that can lead to cancer.
Because of this, patients typically must take acid-reduction medication (e.g., Tagamet, Pepcid) after surgery. Patients also do well to vigilantly observe new dietary habits, such as eating smaller portions, eating more slowly, avoiding high-fat and spicy dishes, and standing or sitting upright for a few hours after meals to minimize reflux and regurgitation.
Effectiveness
One postoperative questionnaire of esophagectomy patients reported that 79 percent experienced “normal or insignificantly impacted eating,” and some patients report a significant reduction in heartburn.
Data associates more favorable surgery outcomes (complication and survival rates) with high-volume centers of patients with esophageal cancer. Mortality rates in low-volume centers are often 15 to 25% with this procedure, while as low as 1% to 2% in high-volume, expert centers.
Risks
The procedure can result in major complications such as leakage at the esophagectomy suture sites, and minor complications such as atrial fibrillation, pneumonia, lung collapse, bowel obstruction and loss of function to the diaphragm.
With any surgery emerge risks of bleeding, infection and adverse reaction to anesthesia.
What are the risks of not having this treatment/procedure?
In the absence of surgery, esophageal cancer is difficult to treat successfully – occasionally some patients may be candidates for endoscopic removal or treatment with chemotherapy and radiation alone. However, for most patients with esophageal cancer, surgery offers the best chance of cure. A cancer that is not appropriately treated is nearly uniformly fatal. Patients with cancer diagnoses should seriously consider a physician’s recommendation of esophagectomy as life-extending and potentially life-saving.
Urgency
Patients with esophageal cancer should not delay evaluation and treatment of their cancer. That said, the treatment is a complex undertaking, and it may take a few weeks to arrange proper evaluation and treatment. These timeframes have never been shown to have a negative impact on the cancer.