Oesophagectomy is a major surgical procedure to remove all or part of the oesophagus, the tube that carries food from the throat to the stomach. This operation is most commonly performed to treat oesophageal cancer, though it may also be necessary for other serious conditions affecting the oesophagus.

What is Oesophagectomy?

Oesophagectomy refers to the surgical removal of part or all of the oesophagus. The oesophagus is a muscular tube responsible for moving food and liquids from your mouth to your stomach. When this organ becomes diseased or damaged, removing it may become necessary to preserve your health or treat cancer^[1].

During the procedure, surgeons remove the affected portion of the oesophagus along with nearby lymph nodes if cancer is present. After removal, the digestive system must be reconstructed so you can continue to eat and drink. Most commonly, surgeons pull the stomach up into the chest and attach it to the remaining healthy part of the oesophagus. In some cases, if the stomach cannot be used, a portion of the large or small intestine may be used instead to create a new passageway for food^[2].

This is considered one of the most extensive and complex operations in surgery. The procedure typically takes between three to six hours to complete, and recovery can be lengthy and challenging^[4].

Why Someone Might Need an Oesophagectomy

The most common reason for performing an oesophagectomy is to treat oesophageal cancer. Cancer of the oesophagus is a serious condition that often requires surgical removal of the affected tissue to prevent the disease from spreading further. The operation may be done to remove the cancer entirely or to relieve symptoms caused by the tumour^[1].

There are two main types of oesophageal cancer: squamous cell carcinoma, which can develop anywhere along the oesophagus, and adenocarcinoma, which typically starts in the lower part of the oesophagus. Adenocarcinoma has become increasingly common in recent decades, particularly in Western countries^[13].

Beyond cancer, oesophagectomy may also be necessary for certain non-cancerous conditions when other treatments have failed. These include Barrett’s oesophagus (a condition where the lining of the oesophagus changes and develops precancerous cells), severe damage to the oesophageal lining from swallowing harmful substances, end-stage achalasia (a condition where the ring of muscle at the bottom of the oesophagus doesn’t work properly), or severe strictures (narrowing of the oesophagus)^[2].

Types of Oesophagectomy Procedures

There are several different approaches surgeons can use to perform an oesophagectomy. The choice of technique depends on many factors, including where the tumour or damage is located, how much tissue needs to be removed, whether the patient has received radiation therapy before surgery, and the surgeon’s expertise^[3].

One major distinction is between open surgery and minimally invasive approaches. Open surgery involves making larger incisions in the body to access the oesophagus. Surgeons may need to make cuts in the neck, chest, abdomen, or a combination of these areas depending on which part of the oesophagus is affected^[1].

Minimally invasive surgery, on the other hand, uses smaller incisions (typically about one inch long) and special instruments including a camera called a laparoscope or thoracoscope to perform the operation. Some centres also use robotic surgery, where the surgeon controls instruments from a computer station while viewing a magnified screen. Minimally invasive approaches may result in less pain and faster recovery compared to traditional open surgery, though they typically take longer to perform^[1].

There are also several named techniques based on where the incisions are made. A transhiatal oesophagectomy involves incisions in the neck and abdomen. An Ivor Lewis oesophagectomy uses incisions on the right side of the chest and in the abdomen. A McKeown oesophagectomy, also called a three-hole approach, requires incisions in the neck, chest, and abdomen. Finally, a thoracoabdominal oesophagectomy uses a single large incision from the chest to the abdomen on the left side, plus an incision in the neck^[1].

Many surgeons use a hybrid approach, combining minimally invasive techniques for one part of the surgery with open surgery for another part. This can help balance the benefits of smaller incisions with the need to work efficiently^[3].

Preparing for Oesophagectomy

Because oesophagectomy is such a major operation, careful preparation is essential. Your medical team will perform numerous tests before surgery to make sure you are healthy enough for the procedure and to plan the operation carefully^[1].

You will likely need imaging tests such as a CT scan (computed tomography) of your chest and abdomen, an endoscopic ultrasound, or a PET scan (positron emission tomography). These tests help your doctors see exactly where the diseased tissue is located and determine how much needs to be removed^[1].

If you have oesophageal cancer, you may need to undergo chemotherapy, radiation therapy, or both before your surgery. Studies have shown that receiving these treatments beforehand can lead to better long-term outcomes for many people. This approach, called neoadjuvant therapy, can help shrink tumours and make them easier to remove surgically^[1].

Your healthcare team will also want to ensure that any existing health conditions, such as diabetes or high blood pressure, are well-controlled before surgery. Managing these conditions beforehand can reduce the risk of complications after the operation^[1].

During the operation itself, you will be under general anaesthesia, which means you will be completely asleep and unable to feel anything. Your surgeon will perform an upper endoscopy at the start of surgery to examine the exact location and extent of the problem. If you have cancer in the upper or middle oesophagus, they may also perform a bronchoscopy to check if the disease has affected your airways^[3].

What Happens During the Operation

The specific steps of an oesophagectomy vary depending on which technique your surgeon uses, but all versions share some common elements. The surgeon begins by carefully freeing the oesophagus from the surrounding tissues. They then remove the diseased portion of the oesophagus along with some surrounding healthy tissue to ensure all affected areas are eliminated^[4].

If you have cancer, the surgeon will also remove nearby lymph nodes during the operation. Lymph nodes are small bean-shaped structures that are part of your immune system. Removing them helps doctors determine if cancer cells have spread beyond the oesophagus and reduces the risk of cancer returning in the future. This removal of lymph nodes is called a lymphadenectomy or lymph node dissection^[6].

After removing the affected portion of the oesophagus, the surgeon must reconstruct your digestive tract. In most cases, they will pull your stomach up into your chest and attach it to the remaining healthy part of your oesophagus. The stomach is reshaped into a tube-like structure to replace the removed oesophagus. Sometimes, if the cancer is located where the oesophagus meets the stomach, the surgeon may need to remove the top part of your stomach as well. This combined procedure is called an oesophago-gastrectomy^[6].

In rare cases where the stomach cannot be used for reconstruction, the surgeon may use a portion of your small or large intestine instead to create the new food passageway^[2].

Before completing the surgery, your surgeon will place a feeding tube, usually into your small intestine. This tube, often called a J-tube, will allow you to receive nutrition while your body heals and before you can safely eat by mouth again^[4].

After the Surgery: Hospital Recovery

After an oesophagectomy, you will wake up in an intensive care unit or high dependency unit where you can be monitored very closely. This is normal for such a major operation. You will have one-to-one nursing care, and your medical team will check on you regularly^[20].

When you first wake up, you will find several tubes and devices attached to your body. These might seem frightening, but each one serves an important purpose. You will likely have tubes draining your wounds, a tube in your bladder to measure urine output, intravenous lines delivering fluids and medications, possibly a chest drain to help your lung expand properly, a tube down your nose into your stomach to prevent nausea, and equipment to control pain medication. You may also have an oxygen mask^[20].

Pain management is an important part of your recovery. You may have pain medication delivered through an epidural (a small tube placed in your back that goes into the fluid surrounding your spinal cord) or through patient-controlled analgesia, which allows you to press a button to receive pain medication when you need it. The amount of medication is controlled by the medical staff to ensure safety^[20].

It is extremely important to perform breathing exercises after surgery. Your lung may have been collapsed during the operation, and you need to expand it fully to prevent fluid build-up that could lead to pneumonia. You will use a device called a spirometer to measure your breathing strength and will be asked to cough regularly, even though this may be uncomfortable^[22].

You will not be allowed to eat or drink anything for several days after surgery. This is because there is a risk of leakage where the surgeon connected your oesophagus to your stomach. A leak at this junction could allow food and fluid to enter your chest cavity and cause serious infection. Before you are allowed to eat, your doctors will perform special tests, often an x-ray with contrast dye, to make sure the connection is healing properly and there are no leaks^[22].

When tests show that eating is safe, you will start with tiny sips of water, then gradually progress to soft foods over time. During this period, you will continue to receive nutrition through your feeding tube^[20].

Recovery at Home

Most people spend about one to two weeks in the hospital after oesophagectomy, though this can vary. When you go home, your recovery will continue for many months. It’s common for people to be surprised by how long full recovery takes. It can take six to twelve months before you feel back to your normal self, and sometimes even longer if you need additional cancer treatments like chemotherapy^[17].

During the first two weeks at home, you may feel quite vulnerable and tired. It helps to have someone at home with you to assist with daily tasks, medication management, nutrition, and personal care^[21].

Your wounds will continue healing for several weeks. It’s normal for wounds to tingle, itch, or feel slightly numb. They may also feel hard, lumpy, or tight as they heal. You should keep your wounds clean and dry, and contact your doctor if they become very painful, start to discharge fluid, or become red and inflamed^[21].

You will go home with several medications to take regularly. These typically include tablets to reduce stomach acid (which helps prevent reflux and allows you to eat more comfortably), anti-sickness medications, and pain relievers. Take these as directed by your medical team. As your pain decreases over time, you can gradually reduce your pain medication, first by lowering the dose and then by taking it less frequently^[21].

Changes to Eating and Nutrition

One of the biggest adjustments after oesophagectomy involves learning to eat again. The surgery dramatically reduces the size of your stomach, similar to gastric bypass surgery. This means you will no longer be able to eat large meals. Most people can only eat small amounts at one time, typically less than the size of a fist^[22].

For the first two weeks after going home, you will likely be advised to eat only pureed or very soft foods. After this period, you can gradually increase the texture and amount of food you eat. You should aim to have five to six small meals or snacks throughout the day rather than three larger meals. Stop eating as soon as you begin to feel full or uncomfortable^[21].

Take your time when eating and chew food very thoroughly. Soft, moist foods are usually easier to tolerate than dry or tough foods. Some people find that certain foods, like soft bread, tough meats, or fibrous vegetables, can feel like they are “sticking” and cause discomfort. Only you can determine which foods you tolerate well, and you may need to avoid some foods permanently^[18].

It’s best not to drink liquids while eating solid food, as this can make you feel full too quickly and reduce the amount of nutrition you get from food. Try to drink fluids between meals instead. Aim for six to eight glasses of fluids daily^[21].

You will continue using your feeding tube for several weeks or even months after surgery until you can eat enough by mouth to maintain your nutrition. Your healthcare team will teach you how to use the tube properly and will remove it once you are eating well enough on your own, typically four to six weeks after surgery, though it may take longer^[17].

Weight loss is common and expected after oesophagectomy, especially in the early months. Working with a dietitian can help you maximise your nutrition and maintain a healthy weight. You will need to focus on eating high-calorie, high-protein foods to support healing and maintain your strength^[21].

Some people experience a condition called dumping syndrome after oesophagectomy. This occurs when food moves too quickly from the stomach into the intestines. It can cause light-headedness, nausea, cramps, and diarrhoea, particularly after eating rich or fatty meals. Your medical team can provide guidance on managing this if it occurs^[17].

Potential Complications and Risks

As with any major surgery, oesophagectomy carries risks both during and after the procedure. The more extensive the surgery, the greater these risks tend to be. Hospitals that perform the greatest number of oesophagectomies generally have better outcomes with lower rates of complications and deaths. This is why choosing a medical centre with significant experience in this operation is so important^[22].

Several factors can increase the risk of complications. People who are older than 60, cannot walk even short distances before surgery, are heavy smokers, are obese, have lost significant weight from cancer, take steroid medications, have had severe infections, or received chemotherapy before surgery may face higher risks^[4].

General risks of surgery and anaesthesia include allergic reactions to medications, breathing problems, bleeding, blood clots, and infections. Specific risks of oesophagectomy include injury to the stomach, intestines, lungs, or other organs during surgery; injury to large blood vessels in the chest; leakage at the site where the oesophagus and stomach were joined together; narrowing of this connection over time; pneumonia; difficulty swallowing or speaking; acid reflux; bowel obstruction; and problems with the feeding tube^[4].

One of the most serious complications is an anastomotic leak – when the connection between the oesophagus and stomach doesn’t heal properly and develops a hole. This can allow food and digestive fluids to leak into the chest cavity, causing infection. This complication requires immediate medical attention and may need additional surgery to repair^[14].

Long-term Outlook and Quality of Life

Recovery from oesophagectomy is a gradual process that requires patience and perseverance. Most people need at least six to twelve weeks before they can return to work or their normal routines. Full recovery of strength and energy can take three to four months or longer, particularly if additional cancer treatments are needed^[17].

Over time, your remaining stomach tissue will gradually stretch, allowing you to eat somewhat larger portions, though you will never be able to eat as much as you could before surgery. Many people find that food tastes different for a long time after the operation, and appetite may remain reduced. It’s common to feel frustrated by how slowly recovery progresses, but this is a normal part of healing from such extensive surgery^[21].

You will need regular follow-up appointments with your surgical team, oncologist if you had cancer, and dietitian. These visits allow your doctors to monitor your recovery, manage any complications, and adjust your treatment plan as needed. You will likely need to take certain medications, particularly acid-reducing tablets, for the rest of your life to prevent reflux and protect your remaining oesophagus^[21].

The emotional impact of oesophagectomy should not be underestimated. Many people experience anxiety, depression, or frustration during recovery. It’s important to communicate with your healthcare team about these feelings. Support groups for people who have had oesophagectomy can be very helpful, as they allow you to connect with others who understand what you’re going through^[22].

Despite the challenges, many people successfully adapt to life after oesophagectomy and go on to live active, fulfilling lives. Working closely with your medical team, following their recommendations, and giving yourself time to heal are the keys to the best possible outcome.