Jefferson Health Northeast

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Esophageal Surgery

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Working in coordination with Jefferson Health – Northeast’s respected Division of Gastroenterology, general surgeons, and thoracic surgeons can offer various surgical procedures to treat conditions of the esophagus – the muscular tube that connects the back of the throat with the top of the stomach. The procedures address these esophageal disorders:

Gastroesophageal Reflux Disease (GERD)

Sometimes this condition is caused by a flaccid sphincter muscle and lax connection at the juncture of the esophagus and the stomach. As a result, acidic stomach juices leak into the bottom of the esophagus. Surgery for severe acid reflux involves restructuring and tightening the area where the esophagus enters the stomach. Jefferson Health – Northeast specialists can often use a laparoscope to perform this operation endoscopically, with minimal invasiveness. This approach requires several small incisions in the abdomen, (however, if laparoscopy is not feasible, open surgery using an incision in the left side of the chest may be necessary). In the operation, the surgeons wrap an upper portion of the stomach around the base of the esophagus, reinforcing the valve structure in his area by creating a kind of collar around it (a procedure called Nissen fundoplication). This operation may be combined with repair of hiatal hernia. Normally, patients stay just one night in the hospital to recover before returning home to complete their recovery from this surgery.

The operation so successful in relieving GERD in the vast majority of cases, that most patients no longer need reflux medications, (note, though, that some patients will experience recurrence of reflux some years later). Patients with significant damage to the esophagus or stomach, related to reflux – such as ulceration or scarring – may need more extensive surgery, involving removal of compromised tissue, to correct these conditions at the same time. Some patients also come for revision or repair of previous reflux operations performed at other centers.

Esophageal Narrowing or Obstruction

Strictures of the esophagus can be caused by abnormal growths or malignancies, anatomical deformations, or even severe reflux disease. They can cause difficulty in swallowing and can obstruct food passage into the stomach. Using endoscopy, surgical specialists can place special tubes called stents across the compromised area of the esophagus to expand its opening. These stents, usually made of fine wire mesh, are left behind and remain in place to maintain the opening of the esophagus. The team will sometimes combine this step with laser surgery to remove tissue intruding on the esophageal opening. Stents must sometimes be replaced in order reposition them or reestablish them. These stents most often serve as palliative treatment for esophageal cancer.

Esophageal Motility Disorders, such as Achalasia

In these conditions, the esophagus lacks the muscular contractions in its lower half necessary to move food adequately into the stomach. In addition, the valve at the bottom of the esophagus, just above the juncture of the stomach, fails to open to allow food to enter the stomach. This condition will worsen if left treated. Specialists recommend some patients for endoscopic treatment via the esophagus itself, but a substantial portion will need surgery, which provides more dependable relief of the condition. In this well-established operation, called a minimally invasive esophageal myotomy, the surgeon cuts the thickened muscles of the valve between the esophagus and stomach. This allows passage of food and can be performed laparoscopically through several small slits made in the abdomen. Usually, the surgeon will also perform at least a partial stomach wrap around the site (as in GERD treatment) to minimize reflux through the newly opened sphincter area. Patients who receive this surgery laparoscopically will typically need to stay one to two days in the hospital. Those who undergo the procedure through conventional, open surgery (through an incision in the chest or abdomen) will need up to one week in the hospital

Esophageal Cancer

While not among the most common malignancies, esophageal cancer is on the rise. It is most common in patients who suffer from a severe form of GERD called Barrett’s esophagus. To learn more about surgery for cancer of the esophagus, see Jefferson Health – Northeast’s Division of Surgical Oncology.

Esophageal Perforation

Sometimes the esophagus may be inadvertently punctured as a result of a diagnostic or surgical procedure. Such a hole in the esophagus is a serious complication, but specialists can repair it by placing an esophageal stent across the compromised area of esophagus. The stent remains in place while the perforation heals and is then removed, sparing the patient from having to undergo surgery to repair such perforations.

Jefferson Health – Northeast’s general surgeons work in coordination with other specialists and with their patient’s referring or family physician when providing surgery for esophageal conditions.

Surgery for Cancer of the Esophagus

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.