Esophageal Resection

Definition

An esophageal resection is the surgical removal of the esophagus, nearby lymph nodes, and sometimes a portion of the stomach. The esophagus is a hollow muscular tube that passes through the chest from the mouth to the stomach—a "foodpipe" that carries food and liquids to the stomach for digestion and nutrition. Removal of the esophagus requires reconnecting the remaining part of the esophagus to the stomach to allow swallowing and the continuing passage of food. Part of the stomach or intestine may be used to make this connection. Several surgical techniques and approaches (ways to enter the body) are used, depending on how much or which part of the esophagus needs to be removed; whether or not part of the stomach will be removed; the patient's overall condition; and the surgeon's preference.

There are two basic esophageal resection surgeries. Esophagectomy is the surgical removal of the esophagus or a cancerous (malignant) portion of the esophagus and nearby lymph nodes. Esophagogastrectomy is the surgical removal of the lower esophagus and the upper part of the stomach that connects to the esophagus, performed when cancer has been found in both organs. Lymph nodes in the surrounding area are also removed.

An esophageal resection may be performed in combination with pre- and postoperative radiation and chemotherapy (chemoradiation).

Purpose

An esophagectomy is most often performed to treat early-stage cancer of the esophagus before the cancer has spread (metastasized) to the stomach or other organs. Esophagectomy is also a treatment for esophageal dysplasia (Barrett's esophagus), which is a precancerous condition of the cells in the lining of the esophagus. Lymph nodes are removed to be tested for the presence of cancer cells, which helps to determine if the cancer is spreading. Esophagectomy is also recommended when irreversible damage has occurred as a result of traumatic injury to the esophagus; swallowing of caustic (celldamaging) agents; chronic inflammation; and complex motility (muscle movement) disorders that interfere with the passage of food to the stomach.

An esophagogastrectomy is performed when cancer of the esophagus has been shown to be spreading to nearby lymph nodes and to the stomach, creating new tumors. When cancer invades other tissues in this way, it is said to be metastatic. The goal of esophagogastrectomy is to relieve difficult or painful swallowing (dysphagia) in patients with advanced esophageal cancer, and to prevent or slow the spread of metastases to more distant organs such as the liver or the brain.

Demographics

The candidates for esophageal resection parallel those at high risk for esophageal cancer. Esophageal cancer is found among middle-aged and older adults, with the average age at diagnosis between 55 and 60. Esophageal cancer and esophageal dysplasia occur far more often in men than in women. One type of esophageal cancer (squamous cell carcinoma) occurs more frequently in African Americans; another type (adenocarcinoma) is more common in Caucasian males. Caucasian and Hispanic men with a history of gastroesophageal reflux disease (GERD) are also at increased risk, because GERD has been shown to cause changes in the cells of the esophagus that may lead to cancer. Higher risks are also associated with smoking (45%), alcohol abuse (20%), and lung disorders (23%).

Description

Esophageal cancer is diagnosed in about 13,000 people annually in the United States; it is responsible for approximately 1.5–5% of cancer deaths each year. Although it is not as prevalent as breast and colon cancer, its rate of occurrence is increasing. This rise is thought to be related to an increase in gastroesophageal reflux disease, or GERD.

The esophagus has a muscular opening, or sphincter, at the entrance to the stomach, which usually keeps acid from passing upward. In people with GERD, the esophageal sphincter allows partially digested food and excess stomach acid to flow back into the esophagus. This occurrence is known as regurgitation. Regurgitation continually exposes the lining of the esophagus to large amounts of acid, causing repetitive damage to the cells of the esophageal lining. The result is Barrett's esophagus, a condition in which the normal cells (squamous cells) of the esophageal lining are replaced by the glandular type of cells that normally line the stomach. Glandular cells are more resistant to acid damage but at the same time, they can more readily develop into cancer cells. Studies at New York's Memorial Sloan-Kettering Hospital have shown that only 30% of people diagnosed with Barrett's esophagus will later be diagnosed with cancer; the other 70% will not develop dysplasia, the precancerous condition. Effective medical treatment of acid reflux is thought to be a factor in the low incidence of cancer in people with Barrett's esophagus. Other types of cancer can also occur in the esophagus, including melanoma, sarcoma, and lymphoma.

The risk factors for esophageal cancer include:

• Use of tobacco. The highest risk for esophageal cancer is the combination of smoking and heavy alcohol use.
• Abuse of alcohol.
• Barrett's esophagus as a result of long-term acid reflux disease.
• A low-fiber diet; that is, a diet that is low in fruits and vegetables, and whole grains that retain their outer bran layer. Other dietary risk factors include such vitamin and mineral deficiencies, as low levels of zinc and riboflavin.
• Accidental swallowing of cleaning liquids or other caustic substances in childhood.
• Achalasia. Achalasia is an impaired functioning of the sphincter muscle between the esophagus and the stomach.
• Esophageal webs. These are bands of abnormal tissue in the esophagus that make it difficult to swallow.
• A rare inherited disease called tylosis, in which excess layers of skin grow on the hands and the soles of the feet. People with this condition are almost certain to develop esophageal cancer.

Cancer of the esophagus begins in the inner layers of the tissue that lines the passageway and grows outward. Cancer of the top layer of the esophageal lining is called squamous cell carcinoma; it can occur anywhere along the esophagus, but appears most often in the middle and upper portions. It can spread extensively within the esophagus, requiring the surgical removal of large parts of the esophagus. Adenocarcinoma is the type of cancer that develops in the lower end of the esophagus near the stomach. Both types of cancer may develop in people with Barrett's esophagus. Prior to 1985, squamous cell carcinoma was the most common type of esophageal cancer, but adenocarcinoma of the esophagus and the upper part of the stomach is increasing more rapidly than any other type of cancer in the United States. Up to 83% of patients undergoing esophagectomy have been shown to have adenocarcinoma. This development may be related to such changes in risk factors as decreased smoking and alcohol use as well as increased reflux disease. People at high risk for esophageal cancer should be examined and tested regularly for changes in cell types.

Esophageal cancer is classified in six stages determined by laboratory examination of tissue cells from the esophagus, nearby lymph nodes, and stomach. The six stages are:

• Stage 0. This is the earliest stage of esophageal cancer, in which cancer cells are present only in the innermost lining of the esophagus.
• Stage I. The cancer has spread to deeper layers of cells but has not spread into nearby lymph nodes or organs.
• Stage IIA. The cancer has invaded the muscular layer of the esophageal walls, sometimes as far as the outer wall.
• Stage IIB. The cancer has invaded the lymph nodes near the esophagus and has probably spread into deeper layers of tissue.
• Stage III. Cancer is present in the tissues or lymph nodes near the esophagus, especially in the trachea (windpipe) or stomach.
• Stage IV. The cancer has spread to more distant organs, such as the liver or brain.

Unfortunately, the symptoms of esophageal cancer usually don't appear until the disease has progressed beyond the early stages and is already metastatic. Without early diagnostic screening, patients may wait to consult a doctor only when there is little opportunity for cure. The symptoms of esophageal cancer may include difficulty swallowing or painful swallowing; unexplained weight loss; hiccups; pressure or burning in the chest; hoarseness; lung disorders; or pneumonia.

The decision to perform an esophageal resection will be made when staging tests have confirmed the presence of cancer and its stage. Two-thirds of people who undergo endoscopy, a close examination of the inside lining of the esophagus, and biopsies (testing esophageal tissue cells) will already have cancer, which can progress rapidly. Some will be treated with surgery and others with medical therapy, depending on the stage of the cancer, the patient's general health status, and the degree of risk. Removing the esophagus or the affected portion is the most common treatment for esophageal cancer; it can cure the disease if the cancer is in the early stages and the patient is healthy enough to undergo the stressful surgery. Esophagectomy will be recommended if early-stage cancer or a precancerous condition has been confirmed through extensive diagnostic testing and staging. Esophagectomy is not an option if the cancer has already spread to the stomach. In this case an esophagogastrectomy will usually be performed to remove the cancerous part of the esophagus and the upper part of the stomach.

Esophagectomy

An esophagectomy takes about 6 hours to perform. The patient will be given general anesthesia, keeping him or her unconscious and free of pain during surgery. One of several approaches or incisional strategies will be used, chosen by the surgeon to gain adequate access to the upper abdomen and remove the esophagus or the tumor and the nearby lymph nodes. The four common incisional approaches are: transthoracic, which involves a chest incision; Ivor-Lewis, a side entry through the fifth rib; three-hole esophagectomy, which uses small incisions in the chest and abdomen to accommodate the use of instruments; and transhiatal, which involves a mid-abdominal incision. The approach chosen depends on the extent of the cancer, the location of the tumor or obstruction, and the overall condition of the patient.

In a minimum-access laparoscopic and thorascopic procedure, the surgeon makes several small incisions on the chest and abdomen through which he or she can insert thin telescopic instruments with light sources. The abdomen will be inflated with gas to enlarge the abdominal cavity and give the surgeon a better view of the procedure. First, the camera-tipped laparoscope will be inserted through one small incision, allowing images of the organs in the abdominal area to be displayed on a video monitor in the operating room. If the surgeon is going to use a portion of the stomach to replace the resected esophagus, he or she will first locate the fundus, or upper portion of the stomach. The fundus will be manipulated, stapled off, and removed laparoscopically, to be sutured in place (gastroplasty) as a replacement esophagus.

Next, the surgeon will pass thorascopic instruments into the chest through another incision. The esophagus or cancerous portion of the esophagus will be visualized, manipulated, cut and removed. Lymph nodes in the area will also be removed. Then the surgeon will either pull up a portion of the stomach and connect it to the remaining portion of the esophagus (anastomosis), or use a piece of the stomach or intestine, usually the colon, to reconstruct the esophagus. Either procedure will allow the patient to swallow and pass food and liquid to the stomach after recovery. As discussed above, other approaches may be used to gain access to the affected portion of the esophagus.

There are several variations of an esophagectomy, including:

• Standard open esophagectomy. This technique requires larger incisions to be made in the chest (thoracotomy) and in the abdomen so that the surgeon can dissect the esophagus or cancerous portion and remove it along with the nearby lymph nodes. The esophagus can then be reconnected to the stomach using a portion of either the stomach or the colon.
• Laparoscopic esophagectomy. This is a less invasive technique performed through several small incisions on the chest and abdomen with the camera-tipped laparoscope and a video monitor to guide removal of the esophagus or tumor along with nearby lymph glands.
• Vagal-sparing esophagectomy. This procedure preserves the branches of the vagus nerve that supply the stomach, with only minimal alteration of the size of the stomach and the nerves that control acid production and digestive functions.

Esophagogastrectomy

An esophagogastrectomy is also major surgery performed with the patient under general anesthesia. The surgeon will choose the incisional approach that allows the best possible access for resecting the lower portion of the esophagus and the upper portion of the stomach. The surgeon's decision will depend on the extent of the cancer, the amount of the esophagus that must be removed, and the patient's overall health status. An esophagogastrectomy can be performed as an open procedure through large incisions, or as a laparoscopic procedure through small incisions.

In a minimum-access laparoscopic procedure, several small incisions are made in the patient's abdomen. A laparoscope will be inserted through one small incision, allowing images of the abdominal organs to be displayed on a video monitor. As in an esophagectomy, gas may be used to inflate the abdominal cavity for better viewing and space for the surgeon to maneuver. The cancerous upper portion of the stomach will first be stapled off and resected. The cancerous portion of the esophagus will then be cut and removed along with nearby lymph nodes. Finally, a portion of the stomach will be pulled upward and connected to the remaining portion of the esophagus (anastomosis); or, if most of the esophagus has been removed, a piece of the colon will be used to construct a new esophagus. Sometimes the surgeon must make an incision in the neck in order to gain access to and resect the upper portion of the esophagus, followed by making an anastomosis between the esophagus and a portion of the stomach.

Diagnosis

The diagnosis of esophageal cancer begins with a careful history and a review of symptoms, and involves a number of different diagnostic examinations. An esophagoscopy may be performed in the doctor's office, allowing the doctor to examine the inside of the esophagus with a lighted telescopic tube (esophagoscope). A barium swallow is another common screening test, performed in the radiology (x ray) department of the hospital or in a private radiology office. In a barium swallow, the patient drinks a small amount of radiopaque (visible on xray) barium that will highlight any raised areas on the wall of the esophagus when chest x-rays are taken. The xray studies will reveal irregular patches that may be early cancer or larger irregular areas that may narrow the esophagus and could represent a more advanced stage of cancer. If either of these conditions is present, the doctors will want to confirm the diagnosis of esophageal cancer; determine how far it has invaded the walls of the esophagus; and whether it has spread to nearby lymph nodes or organs. This staging process is essential in order to determine the best treatment for the patient.

One staging technique is a diagnostic procedure called endoscopic ultrasound. The doctor will thread an endoscope, which is a tiny lighted tube with a small ultrasound probe at its tip, into the patient's mouth and down into the esophagus. This procedure allows the inside of the esophagus to be viewed on a monitor to show how far a tumor has invaded the walls of the esophagus. At the same time, the doctor can perform biopsies of esophageal tissue by cutting and removing small pieces for microscopic examination of the cells for cancer staging. Staging tests may also include computed tomography (CT scans); thorascopic and laparoscopic examinations of the chest and abdomen; and positron emission tomography (PET).

Preparation

The patient will be admitted to the hospital on the day of the operation or the day before, and will be taken to a pre-operative nursing unit. The surgeon and anesthesiologist will visit the patient to describe the resection procedure and answer any questions that the patient may have. The standard preoperative blood and urine tests will be performed. Intravenous lines (IV) will be inserted in the patient's vein for the administration of fluids and pain medications during and after the surgery. Sedatives may be given before the patient is taken to the operating room.

Aftercare

Immediately after surgery the patient will be taken to a recovery area where the pulse, body temperature, and heart, lung, and kidney function will be monitored. Several hours later, the patient will be transferred to a concentrated care area. Surgical wound dressings will be kept clean and dry. Pain medication will be given as needed. A chest tube inserted during surgery will be checked for drainage and removed when the drainage stops. A nasogastric (nose to stomach) tube, also placed during surgery, will be used to drain stomach secretions. Nurses will check it regularly and rinse it out. It will eventually be removed by the surgeon. Until the patient is able to swallow soft foods, he or she will be fed intravenously or through a feeding tube that was placed in the small intestine during surgery. Patients will be encouraged to cough and to breathe deeply after surgery to fully expand the lungs and help prevent infection and collapse of the lungs. Walking and movement will also be encouraged to promote a quicker recovery.

About 10–14 days after the surgery, the patient will be given another barium swallow so that the doctor can examine the esophagus for any areas of leaking fluid. If none are seen, the nasogastric tube can be removed. The patient can then begin to sip clear liquids, followed gradually by small amounts of soft foods. Patients being treated for esophageal cancer may begin chemotherapy (cytotoxic or cell-killing medications), radiation therapy, or both, before or soon after discharge from the hospital. Patients typically remain in the hospital as long as two weeks after surgery if no complications have occurred.

When the patient goes home, any remaining bandages must be kept clean and dry. Frequent walking and gentle exercise are encouraged. Because laparoscopic and thorascopic surgery is less invasive and uses only small incisions, there is less trauma to the body, and activity can be resumed more quickly than with open procedures that require larger incisions. The patient should report any fever or chills, persistent pain, or incision drainage to the surgeon. The patient's diet will typically be restricted for a while to soft foods and small portions; a normal diet can be resumed in about a month, but with smaller quantities. Patients are advised not to drive if they are still taking prescribed narcotic pain medications. Daily care and assistance at home is recommended during the recuperation period. Regular medical care and periodic diagnostic testing, such as endoscopic ultrasound, is essential to monitor the condition of the esophagus and to detect recurrence of the cancer or the development of new tumors.

Risks

One of the primary risks associated with esophageal resection surgeries is leakage at the site of the anastomosis, where a new feeding tube was sutured (stitched) to the remaining esophagus. As many as 9% of all patients have been reported to develop leaks, most occurring when a portion of the stomach rather than the colon was used to construct the new section of the esophagus.

Other risks include:

• formation of blood clots that can travel to the heart, lungs, or brain
• nerve injury, which can cause defective emptying of the stomach
• infection
• breathing difficulties and pneumonia
• adverse reactions to anesthesia
• narrowing of the remaining esophagus (strictures), which may cause swallowing problems
• increased acid reflux and heartburn as a result of injury to or removal of the esophageal sphincter

Normal results

Esophageal resection, especially esophagectomy, can be curative if cancer has not spread beyond the esophagus. About 75% of patients undergoing esophagectomy will be found to have metastatic disease that has already spread to other organs. Esophagectomy will reduce symptoms in most patients, especially swallowing difficulties, which will improve the patient's nutritional status as well. Patients whose esophagectomy is preceded and followed by a combination of chemotherapy and radiation treatments have longer periods of survival.

The typical result of an esophagogastrectomy is palliation, which is the relief of symptoms without a cure. Because esophagogastrecomy is always performed when metastases have already been found elsewhere in the body, the procedure may relieve pain and difficulty in swallowing, and may delay the spread of the cancer to the liver and brain. Cure of the disease, however, is not an expectation.

Patients having less invasive laparoscopic and thorascopic resection procedures will experience less pain and fewer complications than patients undergoing open procedures.

Morbidity and mortality rates

Because 75% of all esophagectomy patients and 100% of all esophagogastrectomy patients will have metastatic disease, morbidity and mortality rates for these procedures are high. Thirty-day mortality for esophagectomy ranges from 6–12%; it is 10% or higher for esophagogastrectomy. Survival of early-stage cancer patients after esophagectomy ranges from 17 to 34 months if surgery alone is the treatment. The mortality rate for early-stage cancer patients having esophagectomy alone is higher than when surgery is combined with pre- and post-operative chemoradiation. The three-year survival rate for early-stage cancer patients who received pre- and post-esophagectomy chemoradiation is about 63%. Better staging techniques, more careful selection of patients, and improved surgical techniques are also believed to be responsible for the increase in postoperative survival rates. Recurrence of cancer in esophagectomy patients has been shown to be about 43%. A higher percentage of patients undergoing esophageal resections survive beyond the 30-day postoperative period in hospitals where the surgeons perform these procedures on a regular basis.

Alternatives

People with Barrett's esophagus can be treated with medicine and dietary changes to reduce acid reflux disease. These nonsurgical approaches are effective in relieving heartburn, calming inflamed tissues, and preventing further cell changes.

Fundoplication, or anti-reflux surgery, can strengthen the barrier to acid regurgitation when the lower esophageal sphincter does not work properly, curing GERD and reducing the exposure of the esophagus to excessive amounts of acid.

Photodynamic therapy (PDT) is the injection of a cytotoxic (cell killing) drug in conjunction with laser treatments, delivering benefits comparable to more established treatments. Endoscopic laser treatments that deliver short, powerful laser beams to the tumor through an endoscope can improve swallowing difficulties; however, multiple treatments are required and the benefits are neither long-lasting nor shown to prevent cancer.

BOOKS

American Cancer Society. The American Cancer Society's Complementary and Alternative Cancer Methods Handbook. Atlanta, GA: American Cancer Society, 2002.

Harpham, Wendy S., MD. Diagnosis Cancer: Your Guide Through the First Few Months. New York: W. W. Norton, Inc., 1998.

Heitmiller, R. F., et al. "Esophagus," in Martin D. Abeloff, ed., Clinical Oncology, 2nd ed. New York: Churchill Livingstone, 2000.

ORGANIZATIONS

American Cancer Society. 1599 Clifton Road NE, Atlanta, GA 30329. (800)ACS-2345. <www.cancer.org>.

American Gastroenterological Association. 4930 Del Ray Avenue, Bethesda, MD 20814. (301) 654-2055. <www.gastro.org>.

OTHER

Ferguson, Mark, MD. Esophageal Cancer. Society of Thoracic Surgeons. <www.sts.org/doc4121>.

National Cancer Institute (NCI). General Information About Esophageal Cancer. Bethesda, MD: NCI, 2003.

L. Lee Culvert

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Esophageal resection surgeries are performed in a hospital or medical center operating room by a general surgeon or a thoracic surgeon.

QUESTIONS TO ASK THE DOCTOR

• Why do I need this surgery?
• How will the surgery be performed? How long will it take?
• How many times have you performed this procedure? How often is it performed in this hospital?
• How much discomfort can I expect in the short term? Over the long term?
• Will this surgery cure my cancer? Will it allow me to live longer?
• What are the chances that the cancer will come back?
• What are my options if I don't have the surgery?
• What are the risks involved in having this surgery?
• What kind of care will I need at home afterward?
• How quickly will I recover?