Oesophagectomy

Oesophagectomy is major surgery to remove all or part of the oesophagus, the tube that carries food from your throat to your stomach. This procedure is most often performed to treat oesophageal cancer and requires careful preparation, extensive surgery, and a long recovery period.

Table of contents

• What is an oesophagectomy?
• Why would someone need this surgery?
• Types of oesophagectomy
• Preparing for surgery
• What happens during the procedure
• Risks and complications
• Recovery and healing
• Eating and nutrition after surgery

What is an oesophagectomy?

An oesophagectomy is surgery to remove all or part of your oesophagus (also spelled esophagus). The oesophagus is the tube that moves food and liquid from your throat to your stomach^[1]. After the surgeon removes the damaged part of your oesophagus, they rebuild your digestive system so you can eat. Most commonly, they pull your stomach up into your chest and connect it to the remaining part of your oesophagus^[2]. Sometimes, if your stomach cannot be used, the surgeon may use part of your bowel to replace the removed section of oesophagus^[6].

This is a major operation that affects how your body processes food. The surgery typically takes between 3 to 6 hours to complete^[8].

Why would someone need this surgery?

An oesophagectomy is the most common surgery to treat oesophageal cancer^[1]. Surgeons perform this procedure either to remove the cancer or to relieve symptoms^[2]. The surgery is most effective when the cancer is diagnosed early, before it has spread to other parts of the body.

Besides cancer, an oesophagectomy may also be performed for other conditions. These include Barrett’s oesophagus, a condition where abnormal cells develop in the lining of the oesophagus and may become cancerous if not treated^[2]. The surgery may also be needed for severe damage to the oesophagus caused by conditions like achalasia (when the ring of muscle in the oesophagus does not work properly), strictures (narrowing of the oesophagus), or after swallowing material that damages the oesophageal lining^[4].

Types of oesophagectomy

The specific technique your surgeon uses depends on several factors, including where the tumour or damage is located in your oesophagus and which approach will benefit you most^[1].

Open versus minimally invasive surgery

Your surgeon may perform traditional open surgery, which involves making larger cuts into your skin to access your oesophagus. Alternatively, they may use minimally invasive surgery, which uses smaller incisions^[1]. Minimally invasive approaches include laparoscopic surgery (to access organs in your abdomen) and thoracoscopic surgery (to access organs in your chest). These involve accessing your oesophagus through a few 1-inch incisions^[1]. Some surgeons use robotic surgery, where instruments are controlled by the surgeon from a computer station^[4].

Many surgeons use a hybrid approach, combining minimally invasive techniques for one part of the surgery with open surgery for another part^[3]. When appropriate, minimally invasive procedures can result in reduced pain and faster recovery than conventional surgery^[2].

Surgical techniques based on incision location

The type of surgery you have depends on where the cancer or damage is in your oesophagus. Common techniques include^[1]:

• Transhiatal oesophagectomy: The surgeon makes incisions in your neck and abdomen
• Ivor Lewis oesophagectomy: The surgeon makes one incision on the right side of your chest and another in your abdomen
• McKeown oesophagectomy: The surgeon makes incisions in your neck, chest, and abdomen (also called a three-hole oesophagectomy)
• Thoracoabdominal oesophagectomy: The surgeon makes a single incision from your chest to your abdomen on the left side and another incision in your neck

Your surgeon will explain which approach is best for you and how it will affect your experience and recovery time^[1].

Removing lymph nodes

During your operation, the surgeon examines the oesophagus and surrounding area. They remove lymph nodes (small glands that are part of your immune system) from around your oesophagus^[6]. This is called a lymphadenectomy. The surgeon takes out lymph nodes in case they contain cancer cells that have spread from the main cancer. Removing the nodes reduces the risk of your cancer coming back in the future^[6].

Preparing for surgery

An oesophagectomy is major surgery with a long recovery time. Before having this procedure, you need many tests to ensure you are a strong candidate for surgery^[1]. You may need to change some parts of your daily routine to increase the likelihood of successful surgery.

You may need to^[1]:

• Get imaging tests: You may need procedures including a computed tomography (CT) scan of your chest and abdomen, an endoscopic ultrasound (EUS), or a PET scan (positron emission tomography scan). These procedures allow your doctor to locate the tissue that needs to be removed so they can plan for surgery
• Get preliminary treatments: If you have oesophageal cancer, you may need cancer treatments like chemotherapy (drugs that kill cancer cells) and radiation therapy (treatment using high-energy rays) before surgery. Studies show that getting these treatments beforehand leads to better long-term results for some people
• Ensure you’re healthy enough for surgery: Managing conditions like diabetes and high blood pressure before surgery can reduce the risk of complications afterward

Your medical team will review all available studies, including previous endoscopy (a test using a tube with a camera to look inside your oesophagus), biopsy reports, and imaging scans before the operation^[3]. On the day of surgery, your surgeon will perform an upper endoscopy to note the exact location of the problem and may also perform a bronchoscopy (a test to look inside your airways) for certain types of cancer^[3].

What happens during the procedure

You receive general anaesthesia at the time of your surgery, which will keep you asleep and pain-free^[4]. Your surgeon may insert a breathing tube through your throat into your lungs and connect you to a ventilator that will breathe for you during surgery^[8].

The surgeon makes 3 to 4 small cuts (for minimally invasive surgery) or larger incisions (for open surgery) in your upper belly, chest, or lower neck, depending on the technique being used^[4]. For minimally invasive surgery, a viewing scope called a laparoscope is inserted through one of the cuts. This scope has a light and camera that allows the surgeon to view the area being operated on through a video monitor. Other surgical tools are inserted through the other cuts^[4].

The surgeon frees the oesophagus from nearby tissues. Depending on how much of your oesophagus is diseased, part or most of it is removed^[4]. If part of your oesophagus is removed, the remaining ends are joined together using staples or stitches. If most of your oesophagus is removed, the surgeon reshapes your stomach into a tube to make a new oesophagus and joins it to the remaining part of the oesophagus^[4].

During surgery, lymph nodes in your chest and belly are likely removed to determine if cancer has spread to them^[4]. A feeding tube is placed in your small intestine so that you can be fed while you are recovering from surgery^[4].

Risks and complications

This is major surgery and has many risks, some of them serious^[4]. Your risks may be higher than normal if you are unable to walk even for short distances, are older than 60 years, are a heavy smoker, are obese, have lost a lot of weight from your cancer, are on steroid medicines, have had a severe infection, or had chemotherapy before the surgery^[4].

Risks for anaesthesia and surgery in general include allergic reactions to medicines, breathing problems, bleeding, blood clots, and infection^[4].

Specific risks for oesophagectomy include^[4]:

• Acid reflux (stomach acid backing up into the oesophagus)
• Injury to the stomach, intestines, lungs, or other organs during surgery
• Leakage at the site where the surgeon joined the oesophagus and stomach together
• Narrowing of the connection between your stomach and oesophagus
• Pneumonia (lung infection)
• Difficulty swallowing or speaking
• Injury to large blood vessels in your chest
• Bowel obstruction (blockage)

A major post-operative risk is leakage at the junction of the oesophagus and stomach. A leak here can lead to food and drink entering the chest cavity and causing systemic infection^[22]. Postoperative complications are a major cause of high mortality after oesophageal cancer surgery^[14].

Recovery and healing

Immediately after surgery

Surgery to remove oesophageal cancer is major surgery. After your operation, you usually wake up in the intensive care unit or a high dependency recovery unit^[6]. In intensive care, you have one-to-one nursing care. Your surgeon and anaesthetist review you regularly and watch your progress closely^[20].

When you wake up, you will have several tubes in your body. You may have^[20]:

• Drips to give you blood transfusions and fluids, usually through a vein in your neck
• Wound drains to drain any blood or fluid
• A chest drain to help your lung expand again
• A tube into your bladder (catheter) to measure how much urine you pass
• A small tube into a vein or artery to check your blood pressure
• A fine tube into your back that goes into your spinal fluid (epidural) to help relieve pain
• A tube down your nose into your stomach (nasogastric tube) to drain bile and stop you feeling sick
• An oxygen mask

You will feel drowsy because of the anaesthesia and painkillers. It is common for people to have strange dreams or hallucinations during and after a stay in intensive care. These usually get better with time^[20].

Pain management

It is normal to have pain for the first week or so. You have painkillers to help^[20]. Tell your doctor or nurse as soon as you feel any pain, as they need your help to find the right type and dose of painkiller for you. Immediately after surgery, you might have painkillers through a drip that you control yourself, called patient controlled analgesia (PCA)^[20]. Or you might have painkillers through a small thin tube put into your back, called an epidural^[20].

Wound healing

You have dressings over your wounds. The position and number of wounds you have depend on what type of surgery you had. Most people have 2 wounds after open surgery. You might have 5 or 6 smaller wounds after keyhole surgery^[20]. Your stitches or clips stay in for at least 10 days. The nurse usually takes them out before you go home if they are not dissolvable stitches^[20].

Healing of your wound takes place over a period of time. It is normal for the wound to tingle, itch, or feel slightly numb. It is normal for the wound to feel slightly hard and lumpy. It is normal to experience a slight pulling around the wound^[21].

Recovery timeline

Most people go back to work or their normal routine after 6 to 12 weeks. You will need more time to get better if you need other treatment for cancer, such as chemotherapy. It will take 3 to 4 months to get back to your usual activities^[17].

Many people are surprised how long recovery can take. It can take many months, even a year, before you feel back to full fitness, particularly if there have been complications after surgery^[21]. During your first 2 weeks following discharge, you may feel quite vulnerable, so it is an advantage to have someone at home with you to guide and support you^[21].

Eating and nutrition after surgery

Starting to eat again

Immediately after surgery, you cannot eat or drink. You have fluids through a drip. When you can start to drink again, you begin with sips of water, usually within 24 to 48 hours^[20]. Your doctor might ask for a special X-ray before you start eating or drinking to check that there is no leakage^[20].

A major post-operative risk is leakage at the junction of the oesophagus and the stomach. Therefore, you will be fed nothing by mouth for several days after the operation; even water is denied. You are fed through the feeding tube until tests prove that the junction is sound^[22]. After successful tests, you can begin to eat very soft foods, slowly working toward a more normal diet.

Your diet will go from a clear liquid diet, to a full liquid diet, and then to a soft diet before you can eat normally. This generally takes 1 to 2 months^[17]. Most people are able to eat small amounts within a week or so^[20].

Long-term eating changes

After this operation, people are not able to eat as large a meal as they did before because they feel full more quickly^[21]. The surgery is similar to a gastric bypass in the dramatic reduction of stomach volume. With time, the remaining stomach tissue will stretch back to a more normal size. However, in the first year or so, the food intake per meal is dramatically reduced^[22].

It is also common to lose some weight after you get home. People may not feel as hungry and food may not taste the same for a long time after surgery^[21]. You will be advised to only eat pureed diet for the first 2 weeks after you go home. After this period, you can start to increase the texture and volume of food eaten^[21].

Important advice for eating includes^[21]:

• Do not try to eat large meals. Start with a small amount of food and stop as soon as you begin to feel full or uncomfortable
• Take your time eating and chew your food well
• Try to have 5-6 small meals or snacks each day rather than 2-3 larger meals
• If you do not feel like a cooked meal, have a nourishing snack instead
• Try not to eat and drink at the same time, as this can make you feel full very quickly

Certain foods can block the oesophagus or be difficult to swallow. Some people complain of food “sticking” or have pain behind the breast bone. This may be prevented by sipping fluids when eating solid foods, chewing foods well, eating soft or chopped foods, and avoiding tough, gummy, or stringy foods like soft bread and rolls^[18].

Other digestive issues

You may experience digestive problems for a few months. These include weight loss, a lot of gas, and a problem called dumping syndrome. Dumping syndrome usually occurs after you eat rich or fatty meals. It may cause you to feel light-headed or sick to your stomach, or to have cramps and diarrhoea^[17].

You may also get gastroesophageal reflux symptoms, such as heartburn and reflux of stomach contents, causing intolerance to certain foods, especially acidic, fatty, and very hot or very cold foods. Gas and bloating sometimes occur after surgery^[18].

The feeding tube will come out when you can eat normally and get enough nutrition. This could be about 4 to 6 weeks after surgery, but it could take longer^[17].

It is important to work with a dietitian to help you manage your symptoms and ensure you get adequate nutrition^[18].