Esophagectomy

ALSO KNOWN AS: Transhiatal esophagectomy, transthoracic esophagectomy, esophagogastrectomy

DEFINITION: Esophagectomy is the surgical removal of part of the esophagus for the treatment of cancer or the relief of cancer symptoms. How much of the esophagus is removed is variable, depending on the location of the malignancy or obstruction. The top part of the stomach may also be removed (a procedure referred to as esophagogastrectomy). After the removal of the cancer or obstruction, the stomach is connected to the remaining part of the esophagus, which is restructured into a tube to form a new esophagus.

Cancers diagnosed and treated:Esophageal cancer; high-grade dysplasia with Barrett's esophagus; end-stage diseases including achalasia, hiatal hernia, and gastroesophageal reflux disease (GERD)

Why performed: An esophagectomy may be recommended as a treatment option for patients with cancer of the esophagus or high-grade dysplasia that occurs with Barrett's esophagus. It also may be performed to relieve symptoms associated with benign conditions that affect swallowing, such as achalasia, hiatal hernia, and gastroesophageal reflux disease. Esophagectomy, which includes endoscopic mucosal resection, transhiatal surgery, and Ivor-Lewis surgery, are the surgical treatments available for the treatment of esophageal cancer. Esophagectomy is most successful when performed for patients with early-stage disease.

Because of the complexity of the procedure, an esophagectomy should be performed by an experienced thoracic surgeon at a medical center specializing in the care of patients with esophageal diseases. Research has shown that patients who undergo an esophagectomy at hospitals with thoracic surgeons who perform large numbers of procedures have improved clinical outcomes and lower mortality rates than patients who have an esophagectomy at lower-volume hospitals.

Patient preparation: Tests performed before the procedure include a complete cardiac evaluation, esophageal manometry, esophagoscopy with biopsy, endoscopic ultrasound, computed tomography (CT) scan, positron emission tomography (PET) scan, and blood tests. or radiation therapy may be performed to reduce the size of the tumor before surgery. One week before the procedure, patients must stop taking aspirin and products containing aspirin, ibuprofen, and anticoagulants, as directed by the physician.

Steps of the procedure: General anesthesia is administered. The surgical technique and type of incisions vary, depending on the location and extent of the cancer, the patient’s pulmonary function, and the surgeon’s recommendations. Surgical techniques include the following:

• transhiatal esophagectomy, in which incisions are made in the abdomen and left side of the neck but not in the chest
• transthoracic esophagectomy (Ivor-Lewis procedure), in which incisions are made in the chest wall (thoracotomy) and upper abdomen
• triincisional esophagectomy (McKeown esophagectomy), in which incisions are made in the right chest, abdomen, and left side of the neck
• minimally invasive esophagectomy, in which several 1-inch incisions are made between the ribs, a thoracoscope (small video-scope) is used to view the surgical area, and surgical instruments are inserted through the other incisions; this procedure minimizes trauma, decreases postoperative pain, and promotes a shorter hospital stay and a quicker recovery
• radiofrequency ablation, stenting, robotic-assisted surgery, and lymphadenectomy to remove the surround lymph nodes are also used

The esophagus, the tumor or obstruction, and the affected are removed. The gastrointestinal system is reconstructed: The stomach is connected to the remaining part of the esophagus. Surgery may last from three to six hours.

After the procedure: The patient recovers in an intensive care unit (ICU) for twenty-four to forty-eight hours. The patient is intubated to aid breathing and has a chest tube to drain fluid and air. Medications are given to manage pain. A feeding tube is placed in the small intestine (jejunostomy or J-tube) to provide adequate nutrition during the early postoperative period, when the patient is unable to eat by mouth. The patient performs deep breathing and coughing exercises to remove lung secretions.

Recovery in the hospital takes about seven days, and full recovery usually occurs within six to eight weeks. During recovery at home, the patient is able to gradually advance from clear liquids to soft foods. The J-tube is removed after the esophagus has healed, usually within four weeks after the procedure. The patient’s swallowing mechanism and ability to taste food are usually restored. In some cases, surgical treatment with an esophagectomy may be followed by chemotherapy or radiation therapy.

Risks: The risks of this procedure include leaks from the internal suture line, pneumonia, pulmonary edema, respiratory distress, bleeding, infection, abnormal heart rhythms, pneumothorax (collapsed lung), and persistent pain. The risk of heart attack is rare. Strictures or narrowed areas may occur at the site where the esophagus and stomach were reconstructed, causing difficulty swallowing in as many as 65 percent of patients. The mortality rate (rate of death) associated with esophagectomy differs based on several factors, including where the procedure was performed and for what length of time the mortality rate was recorded. The five-year morality rate for the procedure was between 4.8 and 16 percent.

Results: Despite the risks, surgical advancements have improved the long-term success of the procedure. Two-year survival rates for patients who undergo an esophagectomy to treat esophageal cancer range from 31 to 44 percent, and five-year survival rates averaged 20 percent, with higher survival rates in patients with early-stage cancers. Surgery performed to relieve dysphagia (difficulty swallowing) improves symptoms in 80 percent of patients, according to the American Cancer Society. 

Bibliography

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Ma, J. Y., et al. “Clinicopathologic Characteristics of Esophagectomy for Esophageal Carcinoma in Elderly Patients.” World Journal of Gastroenterology, vol. 12.8, 2006, pp. 1296–99.

MacKenzie, D. J., et al. “Care of Patients after Esophagectomy.” Critical Care Nurse, vol. 24.1, 2004, pp. 16–31.

“Surgery for Esophageal Cancer.” Memorial Sloan Kettering Cancer Center, www.mskcc.org/cancer-care/types/esophageal/treatment/surgery. Accessed 29 June 2024.

“Survival Rates for Esophageal Cancer - Esophageal Cancer Outlook.” American Cancer Society, 17 Jan. 2024, www.cancer.org/cancer/types/esophagus-cancer/detection-diagnosis-staging/survival-rates.html. Accessed 29 June 2024.

Tupper, Haley I., and Jeffrey B. Velotta. “Surgeons Are Humanizing the Esophagectomy.” American College of Surgeons, 7 Feb. 2024, www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2024/february-2024-volume-109-issue-2/surgeons-are-humanizing-the-esophagectomy. Accessed 29 June 2024.

Van Lanshott, J. J., et al. “Hospital Volume and Hospital Mortality for Esophagectomy.” Cancer, vol. 91, 2001, p. 1574.