Open Esophagectomy

    An open esophagectomy, or esophageal resection, is a type of surgery in which some or all of the esophagus is removed. The lymph nodes near the esophagus and the stomach may also be removed during this operation.

    The esophagus is a hollow muscular tube that passes food from your mouth to your stomach during digestion. A connection has to be rebuilt when any part of the esophagus is removed. This allows you to swallow and pass food on to your stomach.

    An open esophagectomy does not refer to a single type of procedure. It can be performed by many different methods and depends on both the patient’s needs and the surgeon’s experience. An open esophagectomy can also be part of a treatment for cancer of the esophagus that includes radiation and chemotherapy.

    Why the Procedure Is Performed

    An open esophagectomy is frequently performed to treat early-stage cancer of the esophagus, before the cancer has spread to the stomach or other organs. It can also be used to treat esophageal dysplasia, a precancerous condition of the cells in the lining of the esophagus.

    In the majority of patients who require an open esophagectomy, cancer has already spread to the lymph nodes, stomach, or other organs.

    An open esophagectomy might also be performed if you have other conditions that make the passage of solid food and liquids into the stomach uncomfortable. Conditions requiring this procedure include:

    • trauma to the esophagus
    • swallowing of caustic (cell damaging) agents such as lye
    • chronic inflammation
    • complicated muscle disorders that prevent the movement of food to the stomach
    • unsuccessful prior esophagus surgery

    How the Procedure Is Performed

    The procedure is performed in a hospital or clinic operating room with a general or thoracic surgeon.

    There are three types of open esophagectomies that a surgeon might perform.

    A transthoracic esophagectomy (TTE) is performed through the chest. The section of the esophagus with cancer and the upper part of the stomach are removed. The remaining portions of the esophagus and stomach are then connected to rebuild a digestive tract. In some cases, part of the colon is used to replace the removed section of esophagus. Lymph nodes in the chest or neck may also be removed if they are cancerous.

    In a transhiatal esophagectomy (THE), the esophagus is removed without opening the chest. Instead, an incision is made from the bottom of the breastbone to the belly button. Another small incision is made on the left side of the neck. The surgeon removes the esophagus, moves the stomach up to the area in the neck where the esophagus was removed, and connects the remaining portion to the stomach in the neck. Lymph nodes in the chest or neck may also be removed if they are cancerous.

    En bloc esophagectomy is the most radical of the esophagectomy procedures. In this procedure, the doctor takes out the esophagus, a portion of the stomach, and all of the lymph nodes in the chest and abdomen. The surgery is performed through the neck, chest, and abdomen. The remainder of the stomach is reshaped and brought up through the chest to replace the esophagus.

    A transthoracic esophagectomy (TTE) is used for:

    • cancer involving the upper two-thirds of the esophagus
    • dysplasia in a condition called Barrett’s esophagus
    • destruction of the lower two-thirds of the esophagus by swallowing caustic agent

    • complications of reflux esophagitis that could not be improved with other procedures

    A transhiatal esophagectomy (THE) is used to:

    • remove cancer of the esophagus
    • remove the esophagus after other procedures have been used to treat cancer of the esophagus
    • narrow or tighten theesophagusto make swallowing less difficult
    • correct problems with the nervous system
    • repair recurrent gastroesophageal reflux

    • repair a hole or injury caused by a caustic agent such as lye

    A radical en bloc esophagectomy is used to treat a potentially curable tumor.

    How to Prepare for the Surgery

    Before Surgery

    Before your surgery, your healthcare provider will:

    • give you a completephysical examination
    • make sure other medical problems you may have—such asdiabetes,high blood pressure, and heart or lung problems—are under control
    • give you nutritional counseling
    • review what you can expect during and after the surgery, and what risks and complications may result from the operation
    • review what medication you will need to take or stop taking before surgery
    • give you advice on how to quit smoking at least a few weeks before your surgery

    You must take some important steps before your surgery is scheduled. For example, do not take any medications that affect blood clotting. Examples include:

    • ibuprofen (Motrin, Advil)
    • aspirin products
    • vitamin E
    • warfarin (Coumadin)
    • ticlopidine(Ticlid)
    • clopidogrel (Plavix)

    Do not smoke cigarettes for at least four weeks before your operation. You may be tested the day of your operation to make sure you haven’t been smoking. If you have, your operation may be cancelled.

    Walk between two and three miles a day to get yourself in the best shape possible.

    The Day of Surgery

    Do not eat or drink anything after midnight the night before your surgery. Take any medication your healthcare provider instructed you to take with a small sip ofwater only.

    This surgery is performed under general anesthesia. This means you will be asleep during surgery. The anesthesiologist may ask you about your medical history to be sure you haven’t had a reaction to anesthesia in the past.

    What to Expect After the Surgery

    You will wake up after the operation attached to a number of tubes and catheters that help monitor your condition. These may include:

    • nasogastric tube—through your nose and into your stomach, to help remove fluids for about three days
    • feeding jejunostomy tube—in your small intestine, to provide nutrition during your hospital stay and until you can eat on your own
    • chest tube—to help drain fluids that often form in the chest after surgery
    • epidural catheter—in the space around your spine, to deliver pain medication when you need it
    • Foley catheter—in your bladder, to monitor your urine for about three days after surgery

    Patients usually stay in the hospital between one and two weeks following the procedure. There will be a scar where the incisions were made.

    Risks and Complications Associated with the Surgery

    As with any surgery, possible risks include:

    • bleeding
    • blood clots in the legs that may travel to the lungs
    • infection
    • a bad reaction to anesthesia
    • leakage and breathing problems
    • heart attack or stroke during surgery

    Complications specific to an open esophagectomy include less common risks of:

    • lung complications (especially pneumonia)
    • severe infection in the chest
    • injury to the stomach, intestines, lungs, or other organs during surgery
    • leakage from your esophagus or stomach where the surgeon joined them together
    • narrowing of the connection between your stomach and esophagus

    Life After an Open Esophagectomy

    An open esophagectomy can have good results and can lead to a good quality of life in the long term. Rates of death following surgery (mortality) have decreased over the past two decades. Today, the best centers in the United States and Europe report mortality rates of between one and two percent following an open esophagectomy.

    Return to Normal

    You can usually return to normal activities about three weeks after surgery. You may be back to your regular diet after a month. However, the reduced size of your stomach will limit how much you can eat. Therefore, you will need to eat smaller amounts.

    Dumping Syndrome

    Your ability to digest fats and sugars will change. This can lead to something called dumping syndrome—cramping and diarrhea as your bowels try to get rid of food it no longer recognizes.

    A dietician can help you work out your meal options to control the symptoms of dumping syndrome.

    Your diet may be the hardest part to adjust to after your surgery, and you may lose weight. However, most patients adjust to the changes in their body and new diet about four to six months after the surgery.