Esophagectomy

Esophagectomy
Intervention
Surgical removal of the esophagus.
ICD-9-CM	42.40
MeSH	D016629

Esophagectomy (US English) or Oesophagectomy (British English) is the surgical removal of all or part of the esophagus.

Medical uses

The principal objective is to remove the esophagus, a part of the gastrointestinal tract ("food pipe"). This procedure is usually done for patients with esophageal cancer. It is normally done to remove cancerous tumors from the body. It is normally done when esophageal cancer is detected early, before it has spread to other parts of the body. Esophagectomy of early stage cancer represents much the best chance of a cure. Despite significant improvements in technique and postoperative care, the long-term survival for esophageal cancer is still poor. Currently multimodality treatment is needed (chemotherapy and radiation therapy) for advanced tumors. Esophagectomy is also occasionally performed for benign disease such as esophageal atresia in children, achalasia, or caustic injury.

In those who have had an esophagectomy for cancer, omentoplasty appears to improve outcomes.^[1]

Classification

Diagram showing before and after an oesophago-gastrectomy

There are two main types of esophagectomy.

• A transhiatal esophagectomy (THE) is performed on the neck and abdomen simultaneously.^[2]
• A transthoracic esophagectomy (TTE) involves opening the thorax (chest).

In most cases, the stomach is transplanted into the neck and the stomach takes the place originally occupied by the esophagus. In some cases, the removed esophagus is replaced by another hollow structure, such as the patient's colon.

Another option which is slowly becoming available is minimally invasive surgery (MIS) which is performed laparoscopically and thoracoscopically.

After surgery, patients may have trouble with a regular diet and may have to consume softer foods, avoid liquids at meals, and stay upright for 1–3 hours after eating. Dysphagia is common and patients are encouraged to chew foods very well or grind their food. Patients may complain of substernal pain that resolves by sipping fluids or regurgitating food. Reflux-type symptoms can be severe, including intolerance to acidic foods and large, fatty meals. Jejunal feeding tubes may be placed during surgery to provide a temporary route of nutrition until oral eating resumes.

Process

Esophagectomy is a very complex operation that can take between 4 and 8 hours to perform. It is best done exclusively by doctors who specialise in upper gastrointestinal surgery. Anesthesia for an esophagectomy is also complex, owing to the problems with managing the patient's airway and lung function during the operation. Lung collapse is highly probable as well as losing function of diaphragm and possible injury of the spleen.

Average mortality rates (deaths either in hospital or within 30 days of surgery) for the operation are around 10% in US hospitals. However, recognized major cancer hospitals typically report mortality rates under 5%. Major complications occur in 10-20% of patients, and some sort of complication (major and minor) occurs in 40%. Time in hospital is usually 1–2 weeks and recovery time 3–6 months. It is possible for the recovery time to take up to a year.

• 

  Diagram showing before and after a partial oesophagectomy

• 

  Diagram showing before and after a total oesophagectomy

• 

  An esophagectomy using the bowel (colon) to replace the esophagus

• 

  Diagram showing the possible scar lines after surgery for oesophageal cancer

References

1. Yuan, Y; Zeng, X; Hu, Y; Xie, T; Zhao, Y (Oct 2, 2014). "Omentoplasty for oesophagogastrostomy after oesophagectomy.". The Cochrane database of systematic reviews 10: CD008446. doi:10.1002/14651858.CD008446.pub3. PMID 25274134.
2. Davies AR, Forshaw MJ, Khan AA, et al. (2008). "Transhiatal esophagectomy in a high volume institution". World journal of surgical oncology 6 (1): 88. doi:10.1186/1477-7819-6-88. PMC 2531176. PMID 18715498.