Surgery for Esophageal Cancer

For some earlier stage esophageal cancers, surgery can be used to try to remove the cancer and some of the normal surrounding tissue. In many cases, surgery is combined with other treatments, such as chemotherapy and/or radiation therapy.

If the cancer has not yet spread far beyond the esophagus, removing part or all of the esophagus (and nearby lymph nodes) may cure the cancer.

In general, stage 0, I, and II esophageal cancers are potentially resectable (removable) with surgery. Most stage III cancers are potentially resectable as well, even when they’ve spread to nearby lymph nodes, as long as the cancer hasn’t grown into nearby vital structures.

Unfortunately, most esophageal cancers are not found at these earlier stages. And even if the cancer is potentially resectable, some people might not be healthy enough for surgery.

Esophagectomy

Surgery to remove some or most of the esophagus is called an esophagectomy.

Often a small part of the stomach is removed as well. The remaining part of the esophagus is then connected to the remaining part of the stomach. Part of the stomach is pulled up into the chest or neck to become the new esophagus.

How much of the esophagus is removed depends on the stage of the tumor and where it’s located:

If the cancer is in the lower part of the esophagus (near the stomach) or at the place where the esophagus and stomach meet (the gastroesophageal junction or GEJ), the surgeon will remove part of the stomach, the part of the esophagus containing the cancer, and about 3 to 4 inches (about 8 to 10 cm) of normal esophagus above this. Then, the stomach is connected to what is left of the esophagus either high in the chest or in the neck.

If the tumor is in the upper or middle part of the esophagus, most of the esophagus will need to be removed to be sure to get enough tissue above the cancer. The stomach will then be brought up and connected to the esophagus in the neck.

If for some reason the stomach can’t be pulled up to attach it to the remaining part of the esophagus, the surgeon may use a piece of the intestine to bridge the gap between the two. When a piece of intestine is used, it must be moved without damaging its blood vessels. If the vessels are damaged, not enough blood will get to that piece of intestine.

Esophagectomy techniques

Esophagectomy can be done in different ways. No matter which technique is used, esophagectomy is not a simple operation, and it may require a long hospital stay. It’s very important to have it done at a center that has a lot of experience in treating these cancers and doing these surgeries.

Comparing open versus minimally invasive approaches: The main advantage of the minimally invasive techniques is that because they use smaller incisions, a person can often leave the hospital sooner, have less pain after the surgery, and recover faster. But this type of surgery might not be the best approach for everyone, based on where the cancer is and how hard it is to remove.

Long-term outcomes are generally about the same no matter which approach is used. Again, the skill and experience of the surgeon is often the most important factor.

Lymph node removal

For either type of esophagectomy, nearby lymph nodes are also removed during the operation. These are then checked in the lab to see if they have cancer cells. Typically, at least 15 lymph nodes are removed during surgery.

If the cancer has spread to the lymph nodes, the outlook is not as good, and the doctor may recommend other treatments after surgery to try to kill any remaining cancer cells.

Possible risks and side effects of esophagectomy

Like most serious operations, esophagus surgery has some risks.

• Short-term risks include reactions to anesthesia, more bleeding than expected, blood clots in the lungs or elsewhere, and infections. Most people will have at least some pain after the operation, which can usually be helped with pain medicines.
• Lung complications are common. Pneumonia may develop, which may lead to a longer hospital stay and can even be life-threatening.
• Some people might have voice changes after the surgery.
• There may be a leak at the place where the stomach (or intestine) is connected to the esophagus, which might require another operation to fix. This is not as common as it used to be because of improvements in surgical techniques.
• Strictures (narrowing) can form where the esophagus is surgically connected to the stomach, which can cause problems swallowing for some people. To relieve this symptom, these strictures can be dilated (opened up) during an upper endoscopy procedure.
• After surgery, the stomach may empty too slowly if the nerves that cause it to contract are damaged by surgery. This can sometimes lead to frequent nausea and vomiting.
• After surgery, bile and stomach contents might back up into the esophagus because the ring-shaped muscle that normally keeps them inside the stomach (the lower esophageal sphincter) is often removed or changed by the surgery. This can cause symptoms such as heartburn. Sometimes antacids or other medicines can help these symptoms.

Some complications from this surgery can be life-threatening. The risk of dying from this operation is related to the surgeon’s experience with these procedures.

In general, the best outcomes are seen with surgeons and hospitals that have the most experience. Any hospital that you consider should be willing to show you their survival statistics.