Surgery for esophageal cancer
Surgery is often used to treat esophageal cancer. The type of surgery you have depends mainly on the size, stage and location of the cancer. When planning surgery, your healthcare team will also consider other factors, such as whether or not you have had other operations, your age and your overall health.
Surgery may be done for different reasons. You may have surgery to:
- completely remove the tumour
- remove as much of the tumour as possible before you have other treatments
- rebuild the gastrointestinal (GI) tract after the esophagus is removed
- ease pain or relieve other symptoms (called palliative treatment)
Doctors may classify esophageal cancer as resectable or unresectable. Resectable means that a tumour can be removed with surgery. Stage 0, I and II cancers are usually resectable. Most stage III esophageal tumours are resectable as long as the cancer has not grown into the laryngeal nerve, trachea (windpipe), aorta, pericardium, spine or other important structures near the esophagus.
Sometimes doctors can’t tell exactly how big an esophageal tumour is, or if it can be completely removed, until they do surgery. They may think that a tumour is resectable based on tests, but then they discover during surgery that it can’t be removed or that it has spread, or metastasized. If doctors find out that the tumour is unresectable or that it has spread, they may do palliative surgery to relieve pain or to prevent or treat symptoms of a blockage.
Some people may have a resectable tumour, but they can’t have surgery for other reasons. For example, the person may not be healthy enough to have surgery because they have severe heart or lung disease. People who can’t have surgery will be offered other treatments.
You may be offered other treatments before or after surgery.
Surgery for esophageal cancer is a difficult operation that can be hard to recover from. You need to be as healthy as possible before you have surgery. You may have the following tests to check your overall health before you are offered surgery.
A health history and physical exam lets your healthcare team check your general health. They will ask if you’ve had surgery to your stomach or colon. Previous abdominal surgery may affect how they can rebuild, or reconstruct, the GI tract if the esophagus needs to be removed.
Blood tests may be done, such as complete blood count (CBC), blood chemistry, coagulation (blood clotting) profile and liver function tests. Find out more about blood tests.
Heart and lung function tests are done to make sure you are healthy enough to have surgery. It is very important to quit smoking before surgery. Your healthcare team may teach you special coughing and breathing exercises to help keep your lungs clear.
Nutritional assessment is done to check your weight and food intake. If esophageal cancer made it difficult for you to eat before you were diagnosed, you may be malnourished and underweight. You may need nutritional supplements, a feeding tube or intravenous feeding for a few days before and after surgery to gain weight and improve your nutrition and health. You may also need antibiotics to prevent or treat infections if poor nutrition has weakened your immune system.
Doctors can use different approaches or methods to enter the body during surgery to treat esophageal cancer and do reconstructive surgery. The type of approach used depends on the size and location of the tumour, how much or which part of the esophagus needs to be removed, whether or not the stomach will be removed, your overall health and the surgeon’s preference. The approach used doesn’t affect whether or not the surgeon can successfully remove the tumour or the side effects, or complications, that can develop after surgery.
The transthoracic approach is also called the Ivor-Lewis approach. It can be used for tumours in the middle or lower esophagus.
The surgeon makes a cut, or incision, from the bottom of the breast bone to the belly button to reach the stomach. The stomach is cut away from the tissues that hold it in place. Then the surgeon makes a cut in the right side of the chest, or thorax, to open the chest wall (called a thoracotomy). The surgeon removes the part of the esophagus that has cancer or all of the esophagus. Then the surgeon will do reconstructive surgery.
The transhiatal approach is commonly used for early stage tumours in the middle or lower esophagus. It may also be used for advanced esophageal cancer when the person isn’t healthy enough to have a thoracotomy (a surgical cut to open the chest wall).
The surgeon makes a cut, or incision, from the bottom of the breast bone to the belly button to reach the stomach and esophagus. The stomach and lower part of the esophagus are cut away from the tissues that hold them in place. The doctor then makes a cut in the left side of the neck to reach the upper and middle parts of the esophagus. These parts of the esophagus are cut away from the tissues that hold them in place. The surgeon removes the part of the esophagus that has cancer or all of the esophagus. Then the surgeon will do reconstructive surgery.
Left thoracoabdominal approach
The left thoracoabdominal approach can be used for cancers in the lower esophagus or gastroesophageal (GE) junction, where the esophagus joins the stomach.
The surgeon makes a cut, or incison, from the middle of the abdomen upwards to the left side of the chest. The esophagus is cut away from the tissues that hold it in place. The surgeon then removes the part of the esophagus that has cancer or all of the esophagus. The surgeon may also make a cut in the left side of the neck to reach the upper and middle parts of the esophagus. Then the surgeon will do reconstructive surgery.
Minimally invasive (MIS) esophagectomy
During minimally invasive (MIS) esophagectomy, the doctor uses an endoscope (a tube-like instrument with a light and lens). The endoscope is placed in the body through small cuts, or incisions, rather than the larger cuts needed for open esophagectomy. As a result, people who have endoscopic techniques usually have a shorter hospital stay and faster recovery time.
MIS esophagectomy and reconstructive surgery are done using both laparoscopic and thoracoscopic surgery.
Laparoscopic surgery is done using a long, flexible tube with a light and lens (called a laparoscope) to view structures or organs inside the body and to remove tissues. The doctor makes 4–6 small cuts in the abdomen to place the laparoscope.
Thoracoscopic surgery is done using a long, flexible tube with a light and lens (called a thoracoscope) to view structures and organs inside the chest, or thorax. The doctor makes small cuts through the chest wall. The thoracoscope and the surgical instruments are passed through separate cuts into the chest cavity. Sometimes doctors pass a small video camera through the thoracoscope to help them see inside the chest cavity. This is called video-assisted thoracoscopy (VAT), or video-assisted thoracic surgery (VATS).
Esophagectomy is the most common type of surgery used to treat esophageal cancer. It removes part or all of the esophagus. Lymph nodes close to the esophagus are also removed during surgery to see if cancer has spread to them. Sometimes a small part of the stomach is removed during esophagectomy to get a clean margin of healthy tissue around the tumour. How much of the esophagus is removed, and whether or not part of the stomach is removed, depends on where the tumour is located.
Sometimes cancer develops in the lower part of the esophagus near the stomach or at the gastroesophageal (GE) junction, where the esophagus and stomach meet. The surgeon will remove the cancerous part of the esophagus, 8–10 cm of normal esophagus above the tumour and part of the stomach. The stomach is then joined to part of the remaining esophagus, which is in either the upper chest or neck.
If the tumour is in the middle esophagus, the surgeon will remove most of the esophagus. The surgeon brings up the stomach and joins it to the part of the esophagus left in the neck. In some cases, the surgeon will use a piece of the colon to replace the part of the esophagus that was removed. The surgeon joins the colon to the part of the esophagus left in the neck and to the stomach.
If the tumour is in the upper part of the esophagus, surgery is not usually used.
Reconstructive surgery is usually done at the same time as surgery to remove the tumour in the esophagus. Reconstructive surgery helps the gastrointestinal (GI) tract work as normally as possible after the cancer is removed.
The type of reconstructive surgery done is based on your personal needs, your overall health, the location and size of the tumour and any treatments you’ve already had. Different surgeons have different preferences and expertise with certain surgical procedures. This will also help them decide which type of reconstructive surgery they do.
When part or all of the esophagus is removed, the best option is a gastric pull-up. The surgeon pulls the stomach up, reshapes it into a tube and joins it to the part of the esophagus that is left. The connection made between the esophagus and the stomach is called an anastomosis.
Reconstruction using the colon or small intestine
The surgeon may use a piece of the colon (the longest part of the large intestine) or a piece of the small intestine to replace the esophagus. This type of surgery is done if the stomach can’t be used for reconstruction. For example, the colon or part of the small intestine may be used if you already had surgery to the stomach.
Surgery may be used to place a feeding tube directly into the middle part of the small intestine (called the jejunum) through an incision, or cut, in the abdomen. This is called a surgical jejunostomy tube. This allows you to get all the nutrients you need as you recover from surgery. In some cases, a feeding tube may be placed directly into the stomach through an incision in the abdomen. This is called a surgical gastrostomy tube.
Find out more about tube feeding.
You and your caregiver will be told what to expect after surgery. The average hospital stay for people who have surgery for esophageal cancer is 9–14 days.
When you wake up, you will have a tube in your nose called a nasogastric tube. The healthcare team uses this tube to drain or suction off fluid and give medicines. You may also have tubes in your chest. These chest tubes are used to drain fluid from the pleural space, which is the space between the lungs and the pleura, and from the surgical sites.
You will have a feeding tube, usually a jejunostomy tube. You will be fed by this tube for the first 5–7 days after surgery because you won’t be able to take in food or drinks through your mouth. The healthcare team will do swallowing tests and x-rays to make sure the gastrointestinal (GI) tract is healed before you can drink or eat through your mouth. At first you will only be allowed sips of liquid. Slowly, you will be able to eat and drink more normally.
A dietitian will give you support and advice about nutrition and any changes that you may have to make to your diet after you leave the hospital.
Questions to ask about surgery
A surgical procedure to join healthy sections of tubular structures in the body (such as the large intestine) to create a new pathway or bypass.
The thin layer of tissue that covers the lungs and lines the chest cavity. It protects and cushions the lungs and produces a fluid that acts like a lubricant so the lungs can move smoothly in the chest cavity.