Surgery for Cancer of the Esophagus

Downtown Cancer Care Right in Your Neighborhood

Many patients diagnosed with esophageal cancer have previously developed Barrett's esophagus, a condition that may or may not have been identified prior to cancer diagnosis.  Barrett's is a risk factor for esophageal cancer.  

The tissue changes in this condition are referred to as Barrett's dysplasia, a precancerous alteration of esophageal cells that sometimes requires surgery for treatment. Specialists in Aria's
Division of Gastroenterology can help evaluate patients for Barrett's and manage factors, such as reflux disease, that can predispose to it. 

Cancer of the esophagus is not as prevalent a form of cancer as many of the major types of cancer, and yet, at any one time, tens of thousands of patients have the condition in the U.S. While the overall incidence of esophageal cancer has remained relatively stable in this country, the incidence of adenocarcinoma of the esophagus, particularly in white males, has increased. This may be due to demographics, lifestyle, and the prevalence of obesity (which can exacerbate reflux disease).

Cancer of the esophagus is sometimes treatable using one of several approaches to removing the cancerous portion of the esophagus surgically. The surgeon resects the segment of the esophagus with tumor tissue in it, as well as nearby lymph nodes. This approach is called an esophagectomy, to refer to removal of an entire section of the esophagus. (This type of operation is also used for some patients who have high-grade dysplasia, or tissue cells with abnormal growth patterns that are at-risk for becoming cancerous.)

After taking out the diseased length of the esophagus, the surgeon will normally pull the top portion of the stomach up into the chest and connect it (in an anastamosis) to the remaining part of the esophagus. The patient will thus have a new esophagus created from the remaining normal portion of the esophagus and the stomach tissue. In some cases in which the top of the stomach is removed and most of the esophagus, the surgeon will create a new passageway from the throat to the stomach. The objective of these operations is to remove the cancer tissue and leave the patient with the ability to swallow.

Multidisciplinary treatment is usually very important for esophageal cancer, and Aria's cancer center takes a true, collaborative, team approach.  Patients who undergo chemotherapy or radiation therapy, will typically have their surgery several weeks after the final treatment. Esophagectomy patients generally stay in the hospital about a week or more after the procedure, at the end of which they have moved from I.V. feeding, to a liquid diet, to regular food.

For a few patients, the area where their stomach and esophagus are newly connected may tighten and narrow while healing or after healing. The surgeon can use special tools, introduced down the throat, to stretch this opening out again nonsurgically. This procedure is called dilation.

The safety level of esophagectomy is acceptable enough that the operation can be performed in older patients as well. Five-year and longer survival rates for patients who had earlier-stage cancers and underwent esophagectomy are good. But the earlier the cancer is diagnosed the better the chance that
treatment will be curative.

Earlier-stage disease, however, usually produces few symptoms, and so esophageal cancer is often advanced at the time it is discovered. In such cases treatment is possible, but patients whose cancer has spread to other organs
such as the liver or lungs, or is otherwise at an advanced stage, are not considered candidates for surgery other than palliative procedures.  (Our team can also surgically treat benign forms of esophageal tumors, such leiomyomas.)

Transhiatal esophagectomy
In this approach to esophagectomy, the surgeon makes incisions in the cervical (neck) area and in the abdomen, and reconnects the esophagus within the neck area. The procedure allows the patient to avoid a chest incision, a kind of wound that generally brings more discomfort and longer recovery than a cervical incision. A chest incision is traditionally associated with greater likelihood of complication due to respiratory function, and infections related to chest incisions can be more challenging to treat. However, cervical incisions make access to the lymph nodes and tissue surrounding the esophagus more difficult and make anastamosis more challenging. Nerve damage, or complications at the anastamosis, may also be more likely with the cervical approach.

With the transhiatal procedure, the surgeon will generally insert a feeding tube for patients who do not already have one. Typically, patients return to eating regular food by the time of discharge, but keep their stomach tube for some time, in case they need additional nutrition during recovery.

Transthoracic esophagectomy
In this technique, the surgeon makes a chest incision between the ribs to access the esophagus, and an incision in the abdomen, and then performs the same resections as in transhiatal esophagectomy. Research suggests that while the transthoracic approach may bring a slightly higher risk of complications, it may also provide a slightly higher long-term cure rate.

Total esophagectomy
In this procedure, the amount of esophagus removed is extensive enough that the surgeon must create a new passageway from the throat to the stomach. Typically, this is done by using a section of the small or large intestine. This is a complex operation that requires care in both the removal of the piece of intestine and its placement for the removed esophagus.

Palliative surgery
Sometimes when imaging studies reveal that the tumor is too advanced or the cancer too widespread to be completely removed, and that curative surgery is thus not possible, surgical treatment can still be beneficial in addressing and reducing symptoms. Esophageal cancers can cause pain or obstruction of the digestive tract.

For tumors that block the esophagus, the surgeon may be able create a bypass. Another option is to dilate the esophagus at the blockage, stretching it open wider at the narrowed area. If it appears that this step would need to be repeated often or the dilation is not sufficient, the surgeon may place a tube in the esophagus to keep it open. Laser surgery to burn away tumor blockage is also an option.

Download this discussion on surgical treatment of adenocarcinoma of the distal esophagus, by Jeffrey T. Brodsky, Chief of Surgical Oncology at Aria Health:  Download file (PDF format).