Esophagectomy

Overview

Esophagectomy is a surgical procedure to remove some or all of the swallowing tube between your mouth and stomach (esophagus) and then reconstruct it using part of another organ, usually the stomach. Esophagectomy is a common treatment for advanced esophageal cancer and is used occasionally for Barrett's esophagus if aggressive precancerous cells are present. An esophagectomy may also be recommended for noncancerous conditions when prior attempts to save the esophagus have failed, such as with end-stage achalasia or strictures, or after ingestion of material that damages the lining of the esophagus.

Why it's done

Esophagectomy is the main surgical treatment for esophageal cancer. It is done either to remove the cancer or to relieve symptoms.

During an open esophagectomy, the surgeon removes all or part of the esophagus through an incision in the neck, chest or abdomen. The esophagus is replaced using another organ, most commonly the stomach but occasionally the small or large intestine.

In most circumstances, esophagectomy can be done with minimally invasive surgery, either by laparoscopy, robot assisted or a combination of these approaches. When the individual situation is appropriate, these procedures are done through several small incisions and can result in reduced pain and faster recovery than conventional surgery.

Risks

Esophagectomy carries a risk of complications, which may include:

• Bleeding
• Infection
• Cough
• Leakage from the surgical connection of the esophagus and stomach
• Changes in your voice
• Acid or bile reflux
• Nausea, vomiting or diarrhea
• Respiratory complications, such as pneumonia
• Swallowing difficulties (dysphagia)
• Atrial fibrillation
• Death

How you prepare

Your doctor and team will discuss concerns you may have about your surgery. If you have cancer, your doctor may recommend chemotherapy or radiation or both, followed by a period of recovery, before an esophagectomy. These decisions will be made based on the stage of your tumor, and staging must be complete prior to any discussion about treatment before surgery.

If you smoke, your doctor will ask you to quit and may recommend a cessation program to help you quit, as smoking greatly increases your risk of complications after surgery.

Food and medications

Talk to your doctor about:

• When you can take your regular medications and whether you can take them before your surgery. This is especially important if you are taking any blood thinners, as some of them need to be stopped a few days in advance of the planned surgery.
• When you should stop eating or drinking the night before the surgery. In some cases, taking additional nutritional shakes and changing to a liquid diet two to three days before surgery will help to empty an esophagus that has a tendency to fill with food and complicate removal of the esophagus.

Clothing and personal items

Your treatment team may recommend that you bring several items to the hospital including:

• A list of your medications
• Personal care items, such as a brush, eyeglasses or hearing aids
• Loosefitting, comfortable clothing or a robe
• A copy of your advance directive
• Items that may help you relax, such as portable music players with headphones or books

Other precautions

Talk to your doctor about:

• Any medications you have brought to the hospital and when you should take medications on the day of the procedure
• Allergies or reactions you have had to medications

Before being admitted to the hospital for your surgery, talk to your family about your hospital stay and discuss help you may need when you return home. Your doctor and treatment team may give you specific instructions to follow during your recovery when you return home.

What you can expect

Before the procedure

An important aspect of esophagectomy is determining which type of procedure is best for you. To guide that decision, specialists use state-of-the-art imaging techniques, such as computerized tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) imaging, as well as endoscopy with biopsies, and endoscopic ultrasound-guided fine-needle biopsies during endoscopy.

During the procedure

An esophagectomy involves removing some or most of the esophagus, a portion of the top of the stomach and nearby lymph nodes if cancer is involved. How much of the esophagus and stomach are removed depends on the stage of the cancer and where it's located. In some circumstances, a portion of the intestine — rather than the stomach — may be pulled up and connected to the esophagus.

Depending on your situation, the surgeon will choose one of the following surgical techniques:

• Open esophagectomy. This approach involves making one or more large incisions in the neck, chest or abdomen. The surgeon may choose a transthoracic esophagectomy, in which the esophagus is removed through incisions in the abdomen and chest. Or the surgeon may perform a transhiatal esophagectomy, in which the incisions are done in the abdomen and neck. Occasionally, a neck, chest and abdominal incision is needed and this is called a three-field esophagectomy.
• Minimally invasive esophagectomy. This type of approach involves removing the esophagus through several small incisions in the abdomen (laparoscopically) or the chest (thoracoscopically). During laparoscopic surgery, the surgeon inserts instruments and a camera-tipped device through the incisions to view and perform the operation without dividing the muscles or breaking a rib. In some centers, this procedure may be robot assisted.

After the procedure

Your doctor will likely recommend tube feeding (enteral nutrition) through a small tube placed through your abdomen that connects to the small bowel. This type of feeding will continue for four to six weeks to ensure adequate nutrition while you recover. Once you resume a normal diet, the stomach's reduced size means you will need to eat more frequent, smaller quantities. You may lose weight after surgery.

Results

Most people report improved quality of life after esophagectomy, but some symptoms usually continue. Your doctor will likely recommend comprehensive follow-up care to prevent complications after surgery and to help you adjust your lifestyle.

Follow-up care includes:

• Lung therapy (pulmonary rehabilitation) to prevent breathing problems
• Pain management to treat heartburn and problems with swallowing
• Nutritional assessments to help with weight loss
• Psychosocial care if needed