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 (uh-sof-uh-JEK-tuh-mee) is a common treatment for advanced esophageal cancer. It's sometimes used for a condition known as Barrett esophagus if precancerous cells are present. Other names for esophagectomy are esophageal resection or esophagus removal surgery.

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.

Types

Depending on your situation, the surgeon will choose an open or minimally invasive surgical technique.

An open esophagectomy involves making one or more cuts, called incisions, in the neck, chest or abdomen. The difference between these procedures is where the incision is made:

• McKeown procedure. Incisions are made in the neck, chest and abdomen. This also is called a three-hole esophagectomy.
• Transhiatal procedure. Incisions are made in the neck and abdomen.
• Ivor Lewis procedure. Incisions are made in the chest and abdomen.

A minimally invasive esophagectomy involves several small incisions in the abdomen or in the chest or both. The procedure through the abdomen is done laparoscopically. The procedure through the chest is done thoracoscopically. During minimally invasive surgery, the surgeon places instruments and a camera-tipped device through the incisions. The surgeon views and performs the operation without dividing the muscles or breaking a rib. This procedure may be robot-assisted or done laparoscopically or thoracoscopically.

The decision about which approach to use is based on your health concern and your medical history following a consultation with your surgeon. Talk with your care team if you have questions about which surgery is suggested.

Why it's done

Esophagectomy is done to remove esophageal cancer. During an open esophageal resection, the surgeon removes all or part of the esophagus through a cut in the neck, chest, belly or a combination. To treat a tumor in the esophagus, the surgeon often removes most of the esophagus below the throat down to the stomach. A portion of the upper stomach may be removed as well.

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 esophagus removal surgery. 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 scan and PET imaging. An upper endoscopy may be done. If ultrasound is used, the procedure is called endoscopic ultrasound (EUS). A tissue sample, called a biopsy, may be collected during the endoscopy.

During the procedure

Depending on your situation, the surgeon will choose an open or minimally invasive approach. 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. Lymph nodes may be removed from the neck, chest and belly, called a lymphadenectomy.

How much of the esophagus and stomach are removed depends on the stage of the cancer and where it's located.

After the procedure

The hospital stay after esophagectomy depends on your surgery, including pain control, return of bowel function and other factors that signal readiness for discharge. How long you stay in the hospital also may depend on how well you heal and if you have other medical conditions.

Your doctor may 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.

In the weeks after surgery, your healthcare team may test how well you can swallow. The care team also may test the new junction between the stomach and the remaining esophagus for evidence of leaks. That can help determine when you can begin eating food by mouth. Although swallowing may be difficult at first, it often gets easier over time.

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. Your care team can suggest protein-rich options to help you gain weight.

If you have reflux, vomiting after eating or trouble swallowing, talk to your healthcare team. Changing what you eat, changing some medicines and following some guidelines when you eat may help. For example, do not lay flat at night and sit upright while eating.

Scarring from esophagectomy depends on the type of surgery you had. There may be a scar on your neck, abdomen or in places around your chest. Talk to your care team about what to expect and how to care for surgical incisions.

Results

Most people report improved quality of life after esophagus resection or removal surgery, 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.

If you had a tumor removed, follow-up tests after esophagectomy can help guide your treatment. Esophageal cancer can come back in the same area, in another part of the body distant from the esophagus or in both. If this does happen, many local and regional recurrences can be treated. Even when a cure isn't possible, treatment may shrink your cancer to slow the cancer's growth. This can relieve pain and other symptoms, and it may help you live longer.