Esophagectomy is the complete removal of the diseased portion of the esophagus and all associated tissues that might contain cancer. This surgery is not always successful and has a 5% to 10% postoperative mortality rate. Aggressive surgery, however, may be justified, particularly for some patients with lesions in the lower half of the esophagus.
The esophagus lies at the very back of the chest, behind the heart, lungs, and windpipe. These have to be moved out of the way or worked around.
After assessing the cancer site, the surgeon will decide whether or not to procede with the surgery. The amount of cancer, and how much it has spread, helps determine how much of the esophagus needs to be removed. This may involve removing adjacent lymph nodes or organs that have cancer, or are suspected of having cancer.
In some cases, the stomach or piece of small intestine is pulled up into the chest and attached to the upper end of the esophagus, above the cancer. In others, a synthetic tube is substituted for the missing piece of esophagus.
Cure rates for this procedure are quite poor, and comparable to primary treatment with
. The mortality rate immediately following surgery is 5% to 10%. This is because of the weakened and malnourished status of the patient by the time the diagnosis is made, the difficulty of the surgery, and its proximity to many vital organsans.
Somewhat better results are obtained for combinations of
and radiation, or of all three modalities.
Complications of esophagectomy are many and severe because the procedure is complex and risky.
Possible complications may include: Reaction to anesthesia or other medications used during surgeryBleedingSerious infections in the chest and/or abdomenLeakage from any of the surgical connections that have been madeSubdiaphragmatic abscess—This refers to an accumulation of pus beneath the diaphragm as a result of intestinal leakage. It usually requires surgical drainage and intensive treatment with antibiotics.Anastomotic fistula—Leakage of air and infected material into the chest or abdomen occuring through an abnormal passage. This condition can be worsened by the presence of stomach acid. It requires surgical drainage with removal of all foreign material and intensive treatment with antibiotics.
After an esophagectomy, you will be in an intensive care unit (ICU) for many days while your lungs, circulation, and digestive tract heal. You will be very closely monitored. You may receive nutrition through intravenous fluids and total parenteral nutrition (TPN). TPN is the injection of nutrients directly into a major vein, which bypasses your digestive tract. Once you are home to recover, it may take even longer before you feel comfortable.
There are many possible complications during recovery from any surgery, particularly a major surgery such as an esophagectomy: Adult respiratory distress syndrome
(ARDS)— Prevents the lungs from adequately exchanging oxygen.
Disseminated intravascular coagulation (DIC)—Abnormalities of blood clotting cause uncontrollable bleeding.Kidney failureCirculatory collapse—The heart and blood vessels may cease supporting blood pressure. Intensive treatment is required to keep organs and the patient alive until effective blood circulation can resume on its own.Sepsis
—A potentially fatal systemic reaction to infection.
Your stay in the hospital may extend over several weeks due to the extensive nature of the surgery and the high rate of severe complications.
Endoscopic resection is a less invasive procedure than open esophagectomy. This generally means that recovery times and hospital stays are shorter. It is an option for people with early stage cancers that have not spread beyond the primary site or into nearby lymph nodes.
Endoscopy uses tubes to insert a lighted camera and surgical instruments.
The endoscope may be inserted through the mouth to remove tumors from the wall of the esophagus in people with early stage cancers.
Endoscopy in late stage cancers may be done through small incisions in the chest to remove all or part of the esophagus, along with surrounding tissues and lymph nodes. Endoscopy is less invasive and allows for faster healing than open esophagectomy.
Most esophageal cancers are detected in late stages, so endoscopic resection may not be an option.
If the cancer has not spread and all of it is removed, endoscopic resection may cure the cancer.
Unfortunately, most esophageal cancers are found late and still require removal of the esophagus, affected lymph nodes, or organs. Success rates for endoscopic resection are similar to open esophagectomy.
Since it's a surgical procedure, complications for endoscopic resection are similar to open esophagectomy. These may include: Reaction to anesthesia or medicationBleedingInfectionLeakageFistula
can be inserted through your abdominal wall and directly into your stomach or small intestine in order to feed you when you cannot swallow. This will help prevent starvation and also help prevent aspiration of material into your lungs.
The feeding tube can be placed as part of another surgical procedure or as a separate out-patient procedure. Once the rubber tube is placed through your skin and into your stomach or small bowel, it is fixed securely, both inside and out, and plugged. The procedure itself takes little time, can be done during
or gastroscopy, and has few complications. It will add no time to your hospital stay or to your recovery from other treatments.
Complete, balanced liquid meals can be delivered through the tube at any time.
Bleeding, infection, or irritation where the tube exits the abdomen are the only likely problems with feeding tubes.
Once you have a feeding tube placed, your nurse will help you care for it. This involves keeping the wound site clean, changing the dressings, and monitoring the site for any signs of infection.
There are a few methods for keeping a route open through relatively natural passages: Laser fulguration through an endoscope
—Tissue that is obstructing the passageway is burned away. This appears to be the most promising of these methods. The effectiveness and specificity of laser treatments can be enhanced by giving you certain chemicals that localize in the cancer tissue and make it more sensitive to the laser. This is called photodynamic therapy (PDT).
Dilation of the esophagus by passing probes of increasing diameter through the narrowing passageway
—This can be done either blindly or through endoscopy. Endoscopy is the insertion of a fiberoptic tube with a lighted tip (an endoscope) through the mouth and down through the gastrointestinal (GI) tract to allow the doctor to view the entire passageway from mouth to stomach.
Tubular metal devices
—These can be placed to bypass the tumor.
Each of these three methods is temporarily effective in allowing you to eat, or at least to drink, but the cancer is still growing and will eventually prevent further attempts to maintain an opening.
The main complications of these methods are the following: Failure to open an adequate channelPerforation of the esophagus
Some healing time will be required after each of these procedures, during which other methods of nourishing will be used. Depending upon the type of procedure and your response to it, you will start on liquid food when your doctor thinks it is safe.