Esophagectomy - open

Description

There are many ways to do this surgery. Talk with your doctor about which type of surgery is best for you. It will depend on where in your esophagus the cancer is, how much it has spread, and how healthy you are.

Laparoscopy is one way to do this surgery. A laparoscope is a tiny camera that is inserted into your belly through a small surgical cut.

Open surgery is another way to do an esophagectomy. Two ways to do an esophagectomy using open surgery are:

Trans-hiatal esophagectomy:

• The surgeon will make two large cuts, one in your neck area and one in your upper belly.
• The surgeon will close off one part of your stomach with staples and cut this section off. This part of your stomach will be used to form a new tube to replace the part of your esophagus that is removed.
• The surgeon will remove the part of your esophagus where the cancer or other problems are.
• The surgeon will join together your rebuilt esophagus and stomach in your neck.
• Lymph nodes in your neck and chest may also be removed if cancer has spread to them.
• The surgeon will place a feeding tube in your small intestine so that you can be fed while you are recovering from the surgery.

Trans-thoracic esophagectomy:

• The surgeon will make two cuts, one in your right chest and one in your upper belly.
• The surgeon will close off one part of your stomach with staples and cut this section off. This part of your stomach will be used to form a new tube to replace the part of your esophagus that is cut out.
• The surgeon will remove the part of your esophagus where the cancer or other problems are.
• The surgeon will join together your rebuilt esophagus and stomach in your neck or chest.
• Lymph nodes in your neck and chest may also be removed if cancer has spread to them.
• The surgeon will place a feeding tube in your small intestine so that you can be fed while you are recovering from the surgery.

The surgeon may also examine and do a biopsy of the lymph nodes in your belly to see if the cancer has spread to them.

En bloc esophagectomy is another type of esophagectomy. It is the most invasive of these procedures.

• To do it, the surgeon will make large cuts in your neck, chest, and belly. All of your esophagus and part of your stomach will be removed.
• The rest of your stomach will be reshaped into a tube and placed in your chest to replace your esophagus. The stomach tube will be connected to the remnant of the esophagus in the neck.
• The surgeon will also remove all lymph nodes in your chest and belly.

Most of these operations take about 3 to 6 hours.

Why the Procedure is Performed

The most common reason for removing part, or all, of your esophagus is to treat cancer. You may also have radiation therapy or chemotherapy before or after surgery.

Surgery to remove the lower part of your esophagus may also be done to treat:

• A condition in which the ring of muscle in the esophagus does not work well (achalasia)
• Severe damage of the lining of the esophagus that can lead to cancer (Barrett esophagus)
• Severe trauma

Risks

Esophagectomy is major surgery and has many possible risks. Some of them are serious. You should discuss these risks with your surgeon.

Risks of this surgery, or for problems after surgery, may be greater than normal if:

• You are unable to walk, even for short distances (this increases the risk of blood clots, lung problems, and pressure sores)
• You are still growing
• You are older than 60 - 65
• You are a heavy smoker
• You are obese
• You have lost a lot of weight from your cancer
• You are on corticosteroids

Risks of any anesthesia are:

• Allergic reactions to medicines
• Breathing problems

Risks of any surgery are:

• Blood clots in the legs that may travel to the lungs
• Blood loss
• Heart attack or stroke during surgery
• Infection, including in the surgical wound, lungs (pneumonia), bladder, or kidney

Risks of this surgery are:

• Acid reflux
• Injury to the stomach, intestines, lungs, or other organs during surgery
• Leakage of the contents of your esophagus or stomach where the surgeon joined them together
• Narrowing of the connection between your stomach and esophagus

Before the Procedure

You will have many doctor visits and medical tests before you have surgery. Some of these are:

• A complete physical examination
• Visits with your doctor to make sure other medical problems you may have, such as diabetes, high blood pressure, and heart or lung problems are under control
• Nutritional counseling
• A visit or class to learn what happens during surgery, what you should expect afterward, and what risks or problems may occur afterward
• If you have recently lost weight, your doctor may put you on IV nutrition for several weeks before surgery

If you are a smoker, you should stop smoking several weeks before surgery. Your doctor or nurse can help.

Tell your doctor or nurse:

• If you are or might be pregnant
• What medicines, vitamins, and other supplements you are taking, even ones you bought without a prescription
• If you have been drinking a lot of alcohol, more than 1 or 2 drinks a day

During the week before surgery:

• You may be asked to stop taking medicines that make it hard for your blood to clot. Some of these are aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), and clopidogrel (Plavix), or ticlopidine (Ticlid).
• Ask your doctor which medicines you should still take on the day of surgery.
• Prepare your home for after surgery.

On the day of surgery:

• Do not eat or drink anything after the midnight before surgery.
• Take the medicines your doctor told you to take with a small sip of water.
• Arrive at the hospital on time.

After the Procedure

Most people stay in the hospital for 7 to 14 days after an esophagectomy. How long you stay will depend on what type of surgery you had. You may spend 1 to 3 days in the intensive care unit (ICU) right after surgery.

You will stay in the hospital for 10 to 14 days after en bloc esophagectomy

During your hospital stay, you will:

• Be asked to sit on the side of your bed and walk on the same day you had surgery
• Not be able to eat for at least the first 2 to 3 days after surgery. After that, you will start with liquids. You will be fed through a feeding tube that goes into your intestine.
• Have a tube coming out of the side of your chest to drain fluids that build up
• Wear special stockings on your feet and legs to prevent blood clots
• Receive shots to prevent blood clots
• Receive pain medicine through an IV or take pills. You may receive your pain medicine through a special pump. With this pump, you press a button to deliver pain medicine when you need it. This allows you to control the amount of pain medicine you get.
• Do breathing exercises to prevent lung infection. 

Outlook (Prognosis)

Many people recover well from this surgery and can eat a fairly normal diet after they recover. Talk with your doctor about the best way to treat cancer.

Alternative Names

Trans-hiatal esophagectomy; Trans-thoracic esophagectomy; En bloc esophagectomy; Removal of the esophagus - open; Ivor-Lewis operation

References

Maish M. Esophagus. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 43.

National Cancer Institute: PDQ esophageal cancer treatment. Bethesda, MD: National Cancer Institute. Date last modified 2/15/2013. Available at:http://www.cancer.gov/cancertopics/pdq/treatment/esophageal/HealthProfessional. Accessed February 20, 2013.

Update Date: 2/6/2013

Updated by: Matthew M. Cooper, MD, FACS, Medical Director, Cardiovascular Surgery, HealthEast Care System, St. Paul, MN. Review provided by VeriMed Healthcare Network. Also reviewed by A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA, Bethanne Black, Stephanie Slon, and Nissi Wang.