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Esophagectomy
Removal of the esophagus

Cancer of the esophagus is the most serious disease of the esophagus seen by surgeons.

  • About 11,000 Americans each year are diagnosed with cancer of the esophagus
  • Though this is not a common cancer, it is almost always fatal unless treated early
  • While this cancer is easy to diagnose, it is difficult to treat and the five-year survival rate is lower than many other cancers

Rupture through the entire wall of the esophagus is an uncommon non-cancerous but life threatening disease of the esophagus that could lead to esophagectomy. This could occur following an episode of severe vomiting.

Anatomy and Physiology

The esophagus, sometimes called the gullet, is a tube-like structure that connects the back of the throat (the pharynx) to the stomach. (Figure 1)

Figure 1 - Anatomy of the esophagus, the tube that guides food and drink from the mouth into the stomach.
  • It is composed mostly of muscle
  • It is about 22 - 27 centimeters (9 to 11 inches) long
  • It serves as the passage for food and saliva to get from the mouth to the stomach.
  • A few inches of the esophagus are in the neck (called the cervical esophagus)
  • Most of the esophagus is located in the chest
  • It passes into the abdomen through the diaphragm, the broad muscular and fibrous structure that separates the chest from the abdominal cavity
  • Only an inch or so of the esophagus is located in the abdominal cavity where it attaches to the stomach
  • The upper and lower ends of the esophagus are not wide opened tubes at all times, but rather have a certain mechanism that functions something like a pinchcock. These are called the upper and lower esophageal sphincters.
  • The inner lining of the esophagus is made up of a tissue called epithelium. Most of the epithelium resembles skin in many respects and is of a cell type called squamous or flat cells

Pathology

  • Squamous cell carcinoma is the cancer originating in the esophagus. This cancer develops from the squamous epithelial cells lining most of the esophagus (Figure 2a)
Figure 2a - Barium swallow esophagram outlining a squamous cell carcinoma of the esophagus. Courtesy A.. Silbergleit, M.D.
  • Adenocarcinoma occurs in about 5% of true esophageal cancer but the numbers for this type cancer are increasing in the United States. This cancer develops from some glandular structures in the lower part of the esophagus.
  • Cancer arising in the upper part of the stomach where it joins the esophagus is also adenocarcinoma. This type cancer frequently invades the lower esophagus and for practical purposes behaves like a true cancer of the esophagus. It is treated the same way as true adenocarcinoma of the esophagus.
  • The cause is unknown but some factors may be
    1. Poor diet
    2. Long-term acid reflux (stomach contents entering the lower esophagus)
    3. Environment since cancer or the esophagus is more common in the Far East and Central Asia
    4. Achalasia (loss of the normal contractions of the esophagus) has been suggested as a cause
    5. Most victims are middle aged or older
    6. Men are more commonly afflicted than women
    7. Black men are three times more likely to develop esophageal cancer
    8. Frequent drinking of hot liquids has been implicated

History and Physical Examination

  • Cancer of the esophagus in the early stages shows no abnormality at all on physical examination. Any realistic chance to cure cancer of the esophagus requires that the disease be identified in an early stage
  • Dysphagia (persistent difficulty in swallowing). Most persons with dysphagia have problems much less serious than cancer. However, any dysphagia at all requires prompt medical attention
    1. Swallowing problems may come and go
    2. Usually first noticed when eating meat, bread, or coarse foods such as raw vegetables. With larger tumors even liquids may be hard to swallow
  • Fullness, pressure, burning, indigestion, heartburn, vomiting, and frequent choking when eating
  • A feeling that food gets stuck behind the breastbone
  • Weight loss, painful swallowing, and chest pain come later, but usually signify advanced stage disease that may be helped but not cured
  • Coughing or hoarseness occasionally occurs

Tests

  • Barium swallow or esophagram. This involves drinking a fluid containing a barium compound that coats the esophagus and tumor so that they show up on x-ray. If the stomach is also looked at, the test is called an upper gastro-intestinal series or upper G.I. series (Figure 2A)
  • A regular chest x-ray is usually obtained at the time of the barium swallow
  • Blood tests to determine if the person is anemic or there is low protein in the blood
  • Esophagoscopy (Figure 2b)
    1. This is performed by the surgeon or gastro-enterologist (a specialist in stomach and bowel diseases)
    2. An esophagoscope is a long, thin cylindrical instrument, which contains fiber optics and allows the inside of the esophagus to be seen on a video screen. It is passed through the mouth into the esophagus. If passed also into the stomach and first part of the small intestine called the duodenum, the procedure is called an esophago-gastro-duodenoscopy (see Panendoscopy)
    3. Biopsy or removal of a small piece of the tumor is carried out if a tumor is seen. This gives a definite diagnosis - noting whether there is malignancy or not and if malignant, what type of malignancy (squamous cell carcinoma or adenocarcinoma)

     

    Figure 2b - Esophagoscopy demonstrates a cancer of the esophagus (tumor). The normal passage (lumen) for food is also seen. Courtesy A.. Silbergleit, M.D.

 

  • CAT (computerized axial tomography) scan of the abdomen to determine whether or not the cancer has spread to the liver or lymph glands (nodes), which are common sites for spread of esophageal cancer
  • Endoscopic ultrasound. This is an addition to esophagoscopy in which tiny ultrasound probe is connected to the end of the endoscope. It allows a deeper view of the wall of the esophagus and gives better idea of tumor depth and whether nearby lymph glands nearby are enlarged
  • Abdominal ultrasound. An ultrasound probe is passed over the abdomen to help determine if there is any tumor present, particularly in the liver

Tumor Staging

  • Tumor staging determines the extent of the tumor
  • TNM system
    1. T stands for the esophageal tumor itself noting how large and especially how deeply the tumor extends into the wall of the esophagus or through the wall from its origin in the lining of the esophagus
      • Tis - the tumor is tiny and only involves the epithelial lining of the esophagus
      • T1 - the tumor is (usually) small and has barely extended beyond the epithelial lining
      • T2 - the tumor invades the muscle layer of the esophageal
      • T3 – the tumor extends through the esophageal wall
      • T4 – the tumor extends through the wall to adjacent structures
    2. N stands for nodes (regional lymph nodes that may be invaded by tumor)
      • N0 – nodes not involved
      • N1 – regional nodes involved
  • M stands for metastasis or the spread of the cancer to other parts of the body distant from the original site
  • M0 - No distant metastasis
  • M1 – Distant metastasis
  • Stages – each stage is defined by the TNM system
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage IIA T2 N0 M0
  T3 N0 M0
Stage IIB T1 N1 M0
 T2N1M0
Stage III  N1M0
  N1M0
Stage IV  N1M1
  • The best chance for a possible cure for esophageal cancer is in the early stages of the disease, Stages 0, I and IIA

Surgical Procedure

  • If the cancer is considered removable, other tests such as heart and lung function tests may be carried out to see if the patient is able to tolerate a major operation
  • The best chance for possible cure is surgical removal of the entire tumor along with a margin of normal esophagus
  • Because the esophagus is a structure that is fixed along most of its course, it is not possible to remove a tumor from the esophagus and bring the remainder of the esophagus together to join the ends (joining is called an anastomosis)
  • In order to remove the tumor, it is necessary to remove that part of the esophagus that contains the tumor, a few inches of esophagus above and the entire esophagus below the tumor as well as the upper part of the stomach (Figure 3A)
  • In the most common operation, the remainder of the stomach, which is mobile, may be brought up towards the upper segment of the esophagus and joined (anastomosed) together (Figure 3B)
Figure 3a - Esophageal tumor in the lower esophagus. The esophagus is freed from surrounding tissues and the esophagus containing the tumor is removed at the lines of incision shown in the esophagus and stomach. Figure 3b - The remaining stomach is 'rolled' into a more tubular structure following which the stomach is freed and drawn upward through the diaphragm to be joined (anastomosed) to the remaining esophagus.
  • If it is not possible to bring up the remaining stomach, a mobile segment of bowel may be brought up and placed between the upper segment of the esophagus and the remaining stomach. This is called a colonic Interposition and requires an additional operation in the abdomen to obtain a piece of bowel (Figures 3 C,D,E)
Figure 3c - When the tumor is higher in the esophagus, occasionally the stomach cannot be freed enough to join the high esophageal segment.

Figure 3d - After removal of the esophagus containing the tumor, a segment of the colon (lower bowel) is taken along with its blood supply (not shown).

Figure 3e - The colon is placed between the upper segment of the esophagus and the middle of the stomach thus forming a channel for food to reach the stomach. The upper end of the stomach is sewn closed.

  • Occasionally the surgeon finds that the tumor cannot be removed because of unrealized size or spread. The surgeon may then carry out a bypass procedure to make eating easier

Complications

  • During surgery (intraoperative)
    1. Intolerance of anesthesia
    2. Hemorrhage (bleeding)
  • Early post-operative
    1. Wound infection
    2. Pneumonia
    3. Blood clots in the legs
    4. Blood clots to the lung (pulmonary embolus)
  • Long term post-operative
    1. Failure of the anastomosis to heal causing a leak of fluid into the tissues surrounding the esophagus
    2. Stricture of the anastomosis that may require stretching (dilatation) of the area
    3. Since surgery cannot match the natural distal esophageal sphincter, the patient may have gastric reflux with heartburn

Post-operative Care

Care is similar to post-operative care following any major operation

  • Fluids are given by vein
  • Only sips of liquid are given at first until your surgeon is satisfied that the anastomosis is healing
  • The patient may be on a ventilator, a machine that assists breathing
  • Pain control is accomplished with pain medication given in the vein or muscle
  • Deep breathing and deep coughing is encouraged to help keep the lungs clear
  • Early movement in bed and walking help prevent blood clots in the legs
  • Low doses of blood thinners also help reduce the chance of blood clots
  • Most esophagectomy patients have a plastic tube in the nose that passes through the anastomosis into the stomach (naso-gastric tube) for a few days. This tube must be secured with extra care to prevent accidental removal since efforts to reinsert a dislodged tube might be hazardous to the anastomosis
  • The patient usually has a chest tube drain for 24-48 hours. This tube allows any fluid, which collects around the lungs, to drain into a bottle (see Thoracotomy)

Post-discharge Care

  • Early care
    1. The patient should be followed closely to make certain that all is progressing well
    2. The patient should be able to eat adequately to maintain weight and strength
    3. Assess for developments such as anemia, pneumonia or fluid in the space between the lungs and the inner chest wall (pleural effusion)
    4. Check for good healing of the incision
  • Later care is carried out with progressively longer intervals between visits and includes
    1. Maintenance of weight
    2. Evaluation of ease of swallowing
    3. Development of late stage heartburn
    4. Assessment at intervals for possible cancer recurrence

Other Forms of Therapy

  • Radiotherapy uses high energy X-rays or other radiation to destroy the cancer cells
    1. It is usually used when the tumor cannot be removed by surgery
    2. Radiotherapy shrinks the tumor thus making swallowing easier
    • It is frequently given with chemotherapy
  • Chemotherapy uses anti-cancer drugs to destroy cancer cells. These drugs disrupt the growth of the cancer cells
    1. May be given with radiotherapy
    2. Used when the cancer cannot be removed by surgery or spread to other parts of the body (metastasis)
    3. It may be used with the object of shrinking the tumor and relieving symptoms
  • Dilatation of a narrowing (stricture) in the esophagus
    1. Progressively larger dilators are passed through stricture to enlarge the space for passage of fluid and food
    2. May be done after surgery or radiotherapy
  • Laser can be used to remove enough tumor to allow passage of food
    1. It is carried out using a special esophagoscope
    2. It may take two treatments to develop a large enough passage for food to pass normally
  • Alcohol injection may be used to shrink the tumor enough to allow food to pass. Small amounts of ethyl alcohol are use