Esophagectomy

What is an esophagectomy?

An esophagectomy is a surgery to remove part or all of the esophagus (the tube through which food travels from the throat to the stomach). It is most often performed for esophageal cancer, a condition in which malignant (cancerous) tumors develop in the esophagus. It may also be performed for benign (nonmalignant) diseases of the esophagus where the esophageal function has deteriorated to the point that the individual can no longer swallow.

What are the different kinds of esophagectomy?

There are several different approaches (surgical methods) for an esophagectomy, depending on the number of incisions (cuts) and where the incisions are made. This is determined by several factors, including where the tumor is located, if the patient has had an earlier surgery, and the preference of the surgeon.

The surgical approaches include the following:

• McKeown esophagectomy: The incisions are made in the neck, chest and abdomen (belly) to remove the esophagus and rebuild the gastrointestinal tract.
• Thoracoabdominal esophagectomy: A single incision is made from the chest to the abdomen on the left side, and an incision is made in the neck.
• Transhiatal esophagectomy: Incisions are made in the neck and abdomen, with the intervening esophagus being dissected out bluntly (with the fingers).
• Ivor Lewis esophagectomy: One incision is on the right side of the chest and the other in the abdomen.
• Minimally invasive esophagectomy: The surgeon may choose to do a portion or all of the esophagectomy using minimally invasive techniques. A robot may be used in the chest and/or abdomen, a thoracoscope may be used in the chest, or a laparoscope may be used in the abdomen. (Thoracoscope and laparoscope are long, thin, flexible instruments for examining the chest and abdomen.) When minimally invasive components are mixed with more traditional “open” components, the procedure is described as a “hybrid” procedure.

Regardless of the type of esophagectomy, a jejunostomy tube (feeding tube) is placed as part of the esophagectomy. This is used to provide nutrition for up to 30 days after the surgery as the patient recovers his or her swallowing function.

The patient will also have a nasogastric tube, a drain that goes in through the nose. This tube is essential for keeping the stomach decompressed in order to give the new connection from the esophagus to the stomach a better chance to heal.

What happens during an esophagectomy?

Before the surgery, the patient is given anesthesia to put him or her to sleep during the operation. An epidural catheter may be placed into the back before the patient goes to sleep in order to aid in postoperative (after the surgery) pain control.

• Depending on the location of the tumor and the surgical approach, the surgeon removes a portion of the esophagus and, an often smaller, portion of the stomach.
• The surgeon then reconnects the remaining esophagus to the stomach, which is pulled up into the chest or neck area (depending on the esophagectomy type).
• The surgeon will also remove lymph nodes so that they can be examined for cancer. Lymph nodes, a part of the body’s immune system, are small oval-shaped structures that filter extracellular fluid or lymph. Identification of cancer in the lymph nodes means the cancer has spread outside the esophagus.

What happens after an esophagectomy?

After an esophagectomy, the patient is taken to the intensive care unit (ICU) for 24-48 hours. He or she will be weaned off the ventilator and started on tube feeds, and the epidural will be adjusted to optimize (maximize) pain control.

The patient is then transferred to the floor where he or she is transitioned to liquid pain medication that can be placed down the feeding tube. The drains and the epidural are eventually removed, and the patient is encouraged to walk. In this phase of care, the patient will be seen by the surgical team, respiratory therapists, physical therapists and social work in order to prepare for discharge to home.

What are the risks of an esophagectomy?

The main risks of an esophagectomy include:

• Pneumonia
• Leaking at the area where the stomach and esophagus are connected
• Bleeding
• Blood clots
• Hoarse voice
• Infection
• Problems swallowing
• Lymphatic leakage

What should I do after an esophagectomy?

After an esophagectomy, follow these steps:

• Check the incision on a regular basis for anything that appears abnormal (signs of infection, bleeding, swelling, draining, discoloration, etc.).
• Wash the incision gently with soap and water.
• Follow the nutrition instructions carefully. The clinic staff will help guide you through the transition from tube feeds to oral feeds. It is important not to rush this process.
• Watch for any major change in your weight (upward or downward).

When should I call my doctor after an esophagectomy?

After an esophagectomy, call your doctor if you:

• Are having pain or fevers that are getting worse.
• Notice warmth, redness, drainage, or bleeding around the incisions.
• Are feeling weak, becoming more short of breath, or feel your heart racing.
• Have diarrhea or black stools.

You should also call your doctor if you have:

• A burning feeling in the throat.
• A cough that doesn’t go away.
• A fever over 101 degrees Fahrenheit.
• Jaundice (yellowing of the whites of the eyes or of the skin).