Esophagectomy

Overview

Esophagectomy is a surgical procedure to remove some or all of the tube connecting the mouth to the stomach, called the esophagus. The esophagus is then reconstructed using part of another organ, usually the stomach.

Esophagectomy is a common treatment for advanced esophageal cancer. It's sometimes used for a condition known as Barrett esophagus if precancerous cells are present.

An esophagectomy also may be recommended for noncancerous conditions when attempts to save the esophagus have failed. This can happen with end-stage achalasia, strictures or after swallowing 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 a cut in the neck, chest, belly or a combination. The esophagus is reconstructed using another organ, most commonly the stomach, but sometimes the small or large intestine.

In some circumstances, esophagectomy can be done with minimally invasive surgery. This includes laparoscopy or robot-assisted techniques. Sometimes, a combination of these approaches may be used. When the individual situation is appropriate, these procedures are done through several small cuts. This can result in reduced pain and faster recovery than conventional surgery.

Risks

Esophagectomy carries a risk of complications, which may include:

• Respiratory complications, such as pneumonia.
• 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.
• Difficulty swallowing, called dysphagia.
• Heart issues, including 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 cancer, 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 program to help you quit. Smoking greatly increases your risk of complications after surgery.

Food and medications

Talk to your doctor about:

• When you can take your regular medicines 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 before the surgery.
• When you should stop eating or drinking the night before the surgery.

Clothing and personal items

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

• A list of your medicines.
• 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 medicines you have brought to the hospital and when you should take medicines on the day of the procedure.
• Allergies or reactions you have had to medicines.

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 CT and PET imaging. An endoscopy may be done. A tissue sample, called a biopsy, may be collected during the endoscopy.

During the procedure

An esophagectomy involves removing some or most of the esophagus. If cancer is involved, a portion of the top of the stomach and nearby lymph nodes may be removed. How much of the esophagus and stomach are removed depends on the stage of the cancer and where it's located. In some circumstances, part 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 cuts, called 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.
• Minimally invasive esophagectomy. This type of approach involves removing the esophagus through several small incisions in the abdomen (laparoscopically) or the chest (thoracoscopically). During minimally invasive surgery, the surgeon places instruments and a camera-tipped device through the incisions to view and perform the operation without dividing the muscles or breaking a rib. Based on your surgeon, this procedure may be robot-assisted or done laparoscopically or thoracoscopically.

After the procedure

Your doctor will likely recommend tube feeding, known as enteral nutrition. Enteral nutrition delivers nutrition through a small tube placed through the abdomen that connects to the stomach or small bowel. This type of feeding will continue until you can tolerate a regular diet and maintain weight without supplementing your diet. Once you resume a regular 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, known as 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.