What is Oesophagectomy?

Introduction

An oesophagectomy is a surgical procedure that involves removing part of the tube (oesophagus) that connects the mouth to the stomach. Oesophagectomy is often used to treat serious cancers of the oesophagus or for other serious non-cancerous causes such as structural damage or collapse of this tube. The removed part is replaced by tissue from another organ, usually the stomach, but there are different methods available. First let us take a look at the anatomy of the oesophagus and when we may need to have it removed.¹

Anatomy of the oesophagus

The oesophagus is part of the digestive system, allowing food to pass from the mouth to the stomach. It is typically 9 to 10 inches (23 to 25 cm) in adults, and follows a path behind the trachea (windpipe) and in front of the spine. The oesophagus has ‘sphincters’ near the upper and lower sections which control when food is able to pass through, and which can contract and close the passage to prevent food moving in the wrong direction. The oesophagus is also lined with a layer of muscle which allows food to smoothly move to the stomach, peristalsis.² 

Indications for esophagectomy

The most common use of an esophagectomy is in the removal of cancers in the oesophagus. The two main types of cancers that affect this part of the body include ‘adenocarcinoma’ and ‘squamous cell carcinoma’. 

• Adenocarcinoma affects the lower end of the oesophagus and develops in cells that make mucus, making it harder to swallow 
• Squamous cell carcinoma affects the cells that line the oesophagus and typically occurs in the upper and middle parts 

There are other conditions that may require an esophagectomy to treat them. 

Barrett’s oesophagus

• A condition where the cells in the lower part of the oesophagus change. This can happen because of long term acid reflux from the stomach. There is a chance it can progress to cancer in the future 
• If doctors find any pre-cancerous cells in an individual with Barrett’s oesophagus they may perform an oesophagectomy in order to remove that part and prevent the formation of any cancer.³ 

Neck trauma

• If an individual suffers from severe damage or trauma to the neck it may cause damage to the structure of the oesophagus. 
• If the muscle layer is broken then the oesophagus may collapse and become unable to stay open. This poses a problem as it obstructs the passage when swallowing, therefore the damaged portion may need to be removed to restore the swallow ability.⁴ 

Types of oesophagectomy

There are many types of esophagectomy that may be performed but we will look at the three main methods that are used. Asking your surgeon to explain why they have chosen a surgical method is important to fully understand their reasoning.

Transhiatal oesophagectomy

This is the most common method and is the most minimally invasive, involving a small incision in the neck through which the oesophagus and a small part of the stomach is removed. The remainder of the stomach is then pulled upwards and reattached to the rest of the oesophagus through a second small cut in the abdomen.⁵ This is done via laparoscopic surgery, also known as keyhole surgery, as the procedure is done by a surgeon making small cuts.

Trans thoracic oesophagectomy

This method is also known as the ‘Ivor Lewis oesophagectomy’ and involves two small incisions, one in the right side of the chest and one in the abdomen.⁶ The procedure is also done laparoscopically, similar to the transhiatal oesophagectomy, where part of the oesophagus is removed and the stomach is pulled up and reattached. 

Thoracoabdominal oesophagectomy

This involves a long incision from the chest to the stomach and a small cut in the neck.⁷ There are many reasons why a surgeon may need to perform this method of surgery, which will depend on the individual needing the procedure. situation.

Preparing for esophagectomy

Before the surgery the doctor will check to make sure you are fit enough to undergo the procedure. This will include: 

• blood tests 
• an ECG 
• X-Rays 

These methods  help to assess the patient’s overall health and if they will be able to tolerate anaesthesia as well as  recovering from the surgery. There will also be a ‘pre-assessment clinic’ where you will speak with the surgeon and other members of the treatment team and is the best opportunity to ask any questions you have about the surgery. The team will advise you on recovery after the procedure. 

When admitted to hospital the doctor or nurse will advise you on when to stop eating and drinking before the surgery. On the day before the surgery you may be given a carbohydrate-rich drink to take the night before. As surgery is a stressful event for the body to undertake it may lose a lot of energy during the procedure, and this drink allows the body to use these nutrients immediately for repair, and reduce the strain felt in the following days. The typical length of the whole hospital stay is around 10-14 days, however, this can vary depending on the surgical method and how fast the body is able to recover afterwards.

Long-term considerations

After the surgery you will feel sore around the stomach and chest areas as well as the locations of any incisions. This may continue for a few weeks while the body heals, and you may need to take pain medicine to feel more comfortable. 

You may experience some digestive problems, especially when eating fatty foods. It is also common to: 

• Lose weight
• Have a lot of gas 

Feel crampingFor the first few weeks you may be on a liquid diet, which includes nutrition shakes, juices, soups and puddings. You can then move to a soft food diet for the next month or two, so that the food you are eating is easy to swallow and digest. After this you may return to a more normal, healthy diet, as it will help in maintaining good stomach function. 

It is important to rest after surgery as you will feel very tired. However, when your energy begins to return it is good to be more active to promote better recovery. 

The doctors will provide advice on medications that you may need to take after the surgery and they will have follow-up appointments to monitor your progress. These medications are used to manage the symptoms you may feel after the surgery such as:

• Fatigue
• Pain when swallowing
• Indigestion/loss of appetite
• Nausea
• Diarrhoea

Risks and complications

While the treatment team does their best to provide the best care there are some risks of developing complications after surgery. These may include⁵

• Respiratory problems, including pneumonia (most common)
• Leaking at the area where your stomach and oesophagus connect (anastomotic leak)
• Irregular heartbeat that can slow blood flow (atrial fibrillation)
• Trouble speaking or swallowing (dysphagia)
• Nausea & vomiting
• Bleeding at the surgery site
• Acid reflux
• Blood clots
• Infection

Summary

An esophagectomy is a surgical procedure that involves the removal of part of the feeding tube that connects the mouth to the stomach. It may be performed on individuals with esophageal cancer, Barrett’s oesophagus or serious esophageal trauma. The surgery is usually done via small incisions which helps to improve recovery with the least complications.