Surgical Removal of the Esophagus (esophagectomy)
The esophagus is a nearly 1 foot long tube that connects the back of the throat to the stomach. The purpose of the esophagus is to transit chewed food from the mouth to the stomach to be digested. The esophagus has three sections named after the departments of the body it passes through; the "cervical" esophagus passes through the neck or "cervical" part of the body, the "thoracic" esophagus passes through the chest or "thorax" and abdominal esophagus enters the belly or "abdomen" by passing through the diaphragm, the thin muscle that separates the thorax from the abdomen.
The surgical removal of the esophagus is called "Esophagectomy". Ectomy means to remove. Just as tonsillectomy means to remove the tonsils, esophagectomy is to remove the esophagus. There are several reasons why the esophagus may need to be removed. The most common reason is to remove a cancer. The most common type of cancer of the esophagus in the United States is adenocarcinoma. The second most common type of cancer is squamous cell carcinoma. Other reasons to remove the esophagus is for pre-cancer (Barrett's mucosa with high grade dysplasia), severe scar or narrowing (such as from severe acid reflux disease), or loss of the ability of the esophagus to transport food (such as from achalasia or injury from multiple surgeries). In order to allow the patient to eat again, the esophagus is usually replaced with the stomach, and rarely a part of the colon.
At the University of California, Davis Medical Center, our Thoracic Surgeons have extensive experience in esophageal surgery. We readily perform the two most common approaches to removal of the esophagus: The Transthoracic Esophagectomy, and the Transhiatal Esophagectomy. The individual characteristics of each patient and his or her esophageal problem guide our surgeons to which procedure to perform.
During the transthoracic (through the chest) esophagectomy, the natural attachments of the esophagus are first loosened up through the patient's abdomen. The patient is then moved over to his or her left side, and through his her right side (transthoracic) more attachments of the esophagus are loosened and the esophagus is removed (esophagectomy). The remaining stomach is then either sewn to the patient's remaining esophagus in the chest area (called an anastomosis), or as high up as in the neck. The advantages of the TTE are that the esophagus is directly visualized during cutting of the attachments. This might make mobilizing the esophagus easier. The disadvantages are that the chest is opened, and that might be more painful for the patient, the surgery may be longer, and if the stomach sewn to the remaining esophagus (anastomosis) is in the chest cavity, if this attachment leaks, it may be very troublesome for the patient.
During the transhiatal (without cutting through the chest) esophagectomy, all of the attachments of the esophagus are loosened through the abdomen and the neck. The esophagus is removed, and the stomach is attached to the esophagus remaining in the neck, without ever entering the patient's chest. The advantages are that the chest is never opened, so there may be less pain, the operation is generally shorter, and the anastomosis is always in the neck. If the anastomosis leaks, it generally is well tolerated by the patient and heals quickly. Because the operation is less invasive than the TTE, the patient often has a shorter hospital stay. The disadvantage is sometimes for sticky esophageal tumors, the surgeon is unable to free up all of the attachments from the abdomen or neck.
Our surgeons will work with you to decide what the best surgery is for you.
What complications can occur after esophagectomy?
Complications after esophagectomy can be divided into two categories: Intraoperative (during the operation) and Postoperative (after the operation). Intraoperative complications include blood loss, injury to the spleen requiring its removal, injury to the trachea and even death. All of these complications have a less than 3% incidence, with death being <1%.
Post-operative complications include leakage from the anastomosis, hoarseness from vocal cord nerve injury, which may or may not be permanent, excessive leakage of chyle (lymph fluid), wound infection, pneumonia and other complications. At the University of California, Davis, we have a top notch nursing team and support staff in both the ICU and the inpatient floor units who quickly identify these potential problems so they are addressed immediately.
What will my life be like after esophagectomy?
There are two main goals of the esophagectomy: 1. cure the disease process, 2. Allow the patient to eat solid food comfortably. Patients who develop a leak after there anastomosis may develop a stricture, or scar at the anastomosis. This may lead to the sensation of food sticking in there throat. This can be generally be resolved with a few sessions of dilation, or widening the anastomosis with a swallowed dilator. Reflux of acid is usually not a problem with the THE, but if it does occur, eating smaller meals and avoiding lying flat may alleviate the problem. Two thirds of patients either gain weight or stay the same weight after the operation, and most patients eventually return to work or their daily activities.
What will I be able to eat after esophagectomy?
Once a diet is initiated in the hospital after esophagectomy, Patients will start with small sips of water or ice chips, followed by clear liquids (juice, decaf coffee without cream, broth, etc…), then full liquids (milk, pudding, etc…) and then Soft Solid food. Soft solid foods include casseroles, stew, fish, pudding, oat meal, for at least two weeks. Then patients can eat whatever they want.
What is dumping syndrome?
Dumping syndrome may occur after any surgery of the upper gastrointestinal tract. Dumping syndrome occurs when the stomach pushes food into the small bowel too fast. The small bowel is unable to handle the food efficiently, and the patient may develop symptoms of dizziness, flushing, sweating, nausea, cramping or vomiting. The symptoms of dumping syndrome can be controlled with a special diet, low in carbohydrates. Dumping syndrome usually disappears with time.