Esophagectomy

Overview

Surgery to remove all or part of your esophagus is known as an esophagectomy. This tube goes from your throat to your stomach, carrying food and liquids. If you have esophageal cancer or your esophagus isn’t functioning properly to aid in swallowing, you might require this operation.

Your surgeon will remove the damaged portion of your esophagus during the treatment, and if you have cancer, some lymph nodes will be removed for testing. After that, they will sew the leftover tissue to rebuild your digestive tract so you can resume eating.

Types

Esophagectomies, surgical removals of the esophagus, vary in technique based on tumor location and individual patient needs. Techniques include:

• Open Esophagectomy: Involves a large single incision to access the esophagus.
• Minimally invasive esophagectomy: Uses smaller incisions, employing laparoscopic (abdominal) or thoracoscopic (chest) surgery for less invasive access.

Common esophagectomy methods are:

• Transhiatal esophagectomy: Incisions made in the neck and abdomen.
• Ivor Lewis esophagectomy: Incisions in the right chest and abdomen.
• McKeown esophagectomy: Incisions in the neck, chest, and abdomen.
• Thoracoabdominal esophagectomy: A long incision from the left chest to abdomen, plus a neck incision.

Reasons for undergoing the procedure

Esophagectomy is a frequently performed surgical procedure for addressing esophageal cancer. This surgical intervention is also employed in the management of conditions that elevate the risk of cancer, such as Barrett’s esophagus, as well as noncancerous conditions that impair the normal functioning of the esophagus.

Risks

After undergoing surgery, it is not uncommon to experience various side effects. Your healthcare team will closely monitor your condition and assist in managing these symptoms. These side effects may include:

• Nausea and vomiting.
• Decreased appetite.
• Gastrointestinal discomfort (such as heartburn, bloating, and gas).
• Fatigue.
• Diarrhea.
• Pain during swallowing.

These symptoms typically improve as your body heals, although some, such as gastrointestinal issues, may persist.

The primary risks associated with an esophagectomy procedure include:

• Respiratory complications, with pneumonia being the most frequent.
• Leakage at the junction where the stomach and esophagus are connected (anastomotic leak).
• Irregular heartbeat, which can impede blood flow (atrial fibrillation).
• Difficulty in speaking or swallowing (dysphagia).
• Nausea and vomiting.
• Bleeding at the surgical site.
• Acid reflux.
• Formation of blood clots.
• Infection.

If you observe any signs of complications, it is crucial to promptly notify your healthcare provider.

Before the procedure

Preparing for an esophagectomy is a crucial step in ensuring a successful surgery and a smooth recovery. To assess your candidacy for the procedure and plan accordingly, several tests and lifestyle adjustments may be necessary:

• Imaging tests: Prior to surgery, you’ll likely undergo various imaging procedures such as a chest and abdomen CT scan, an endoscopic ultrasound (EUS), or a PET scan. These tests help pinpoint the affected tissue and aid in surgical planning.
• Preliminary treatments: If you are diagnosed with esophageal cancer, you might require chemotherapy and radiation therapy before the actual surgery. Research suggests that undergoing these treatments in advance can improve long-term outcomes.
• Preparing your health: Managing pre-existing conditions like diabetes and high blood pressure is essential to reduce the risk of complications post-surgery. Your healthcare provider will also assist you in quitting tobacco and nicotine products as smoking can impede the healing process.
• Preparing for recovery: Collaboration with a dietitian may be necessary to adapt to dietary changes and new eating habits after the removal of the esophagus. Additionally, working with a speech-language pathologist (SLP) can help you learn breathing exercises that strengthen your respiratory muscles, reducing the risk of lung-related complications.
• Hospital stay planning: Expect to spend approximately one to two weeks in the hospital after the procedure. Ensure you pack essential items, including medications, and bring personal comfort items like your preferred pillow and reading material.
• Home recovery preparation: Arrange for someone to drive you home from the hospital and assist you during the initial recovery period. Make modifications around your home to ensure easy access to necessary items without straining yourself.

In the days leading up to your surgery, adhere to your healthcare provider’s instructions regarding medication usage, including the avoidance of blood thinners like aspirin. You may also need to start fasting or switch to a liquid diet to prepare your body for the esophagectomy.

During the procedure

An esophagectomy is a complex surgical procedure involving several critical steps:

• Preparation: Prior to the surgery, you will be administered anesthesia to ensure you are unconscious and pain-free. In some cases, an epidural catheter may be placed in your back for post-operative pain management.
• Incisions: Depending on the specific procedure, your surgeon will make one or more incisions in your neck, chest, or abdomen to access your esophagus.
• Esophagus removal: The surgeon will then carefully remove the diseased or damaged portion of your esophagus. In certain cases, a portion of your stomach may also be removed. In severe cases, the entire stomach might need to be removed.
• Reconnection: Following the removal of the affected esophagus and, if necessary, a part of the stomach, the surgeon will relocate your stomach (or small intestine) to your chest or neck area, depending on the type of surgery. This is done to reconnect it with the remaining portion of the esophagus.
• Lymph node evaluation: If you are undergoing this procedure due to esophageal cancer, your surgeon will also remove lymph nodes for examination in a laboratory. This helps determine if cancer cells have spread beyond the esophagus.
• Feeding tube: Regardless of the type of esophagectomy, a feeding tube will be inserted to provide nutrition during your recovery period, until you regain the ability to swallow. This tube is typically placed in your stomach or small intestine.
• Nasogastric tube: Another tube, known as a nasogastric tube, will be inserted through your nose to remove excess air from your stomach, aiding in the healing process.
• Chest Drains: In some cases, chest drains may be necessary to remove fluid buildup in the chest cavity, further facilitating your recovery.

An esophagectomy is a major and intricate surgical procedure that typically lasts around three to six hours on average. However, the actual duration can vary based on the individual patient’s condition and the complexity of the surgery. To ensure a clear understanding of the procedure and its expected duration, it is crucial for patients to have a thorough discussion with their surgeon beforehand.

After the procedure

Following an esophagectomy, your medical team will transfer you to the intensive care unit (ICU) for a duration of one to two days. During this time, you will begin receiving nutrition through a feeding tube, and the epidural pain management will be tailored to your needs. Your hospital stay after surgery can last up to two weeks.

While in the hospital, your treatment plan will include the following steps to aid in your recovery:

• Pain management: You will transition to liquid pain medications administered through the feeding tube for optimal pain relief.
• Tube removal: Your healthcare team will remove your nasogastric tube and any drains as soon as they are no longer necessary for your recovery.
• Preventing blood clots: To prevent the formation of blood clots, you will be provided with compression stockings and encouraged to start walking around.
• Respiratory care: Breathing exercises, such as deep breaths and coughing, will be incorporated into your daily routine to keep your lungs clear and functioning well.
• Self-care education: You will receive instruction on how to care for your feeding tube and how to properly clean and care for your surgical incision.

During this phase of your care, you will interact with various healthcare providers, including your surgical team, respiratory therapists, physical therapists, and social workers. They will work collaboratively to prepare you for a successful transition back home, ensuring your continued recovery and well-being.

Outcome

Recovery after an esophagectomy involves various adjustments:

• Diet: Initially, you’ll use a feeding tube for up to two months, then transition to liquids and soft foods. Eventually, you can resume a regular diet, but portion sizes and eating frequency may change to accommodate your shorter digestive system. Chewing slowly and cutting food into small pieces can help prevent indigestion.
• Hygiene and wound care: Initially, opt for sponge baths and follow guidance from your healthcare provider on when to switch to showers or baths. Cleaning around your feeding tube and wound care instructions will be provided by your care team.
• Exercise: While you may not feel like it, gentle movement, such as short walks, is important to prevent blood clots. Follow your provider’s guidance on safe activities to avoid overexertion.
• Recovery time: Recovery varies but can take one to two years. Milestones like returning to regular foods and lifting restrictions are important. Everyone’s journey is unique.

When to contact the doctor:

• Call your provider if you have questions or experience worsening pain, fevers, weakness, shortness of breath, rapid heartbeat, digestive issues, or unexplained weight loss.
• Go to the ER or call local emergency immediately if you experience severe swallowing or breathing difficulties, vomiting blood, severe pain (including chest pain), or jaundice.