Esophageal Surgery
The esophagus is a muscular tube that carries food from your mouth to your stomach. A variety of benign and malignant diseases requiring surgical intervention may arise in the esophagus.
High pressure in the lower pharynx (neck portion of the esophagus) by the cricopharyngeus muscle causes an outpouching of the esophagus known as a Zenker’s diverticulum. It mainly affects older adults and may be asymptomatic but, if large, may present as difficulty swallowing, regurgitation of food into the mouth, cough and bad breath. If you have any of these symptoms, your physician may order a barium (contrast) swallow study, a CT scan of the neck with oral contrast, or an upper endoscopy, which will provide the diagnosis. A Zenker’s diverticulum is treated by a small neck incision, dividing the cricopharyngeus muscle and removing the diverticulum, or by endoscopic stapling.
Achalasia is an esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES) at the junction of the esophagus and stomach (GE junction). This causes incomplete emptying of the esophagus and symptoms such as difficulty swallowing, regurgitation and occasionally chest discomfort. Diagnosis is reached by a barium swallow and the characteristic “bird’s beak” appearance, and esophageal manometry, which identifies the high pressure at the LES. For mild disease, drugs that reduce LES pressure, such as calcium channel blockers or nitrates, may be helpful, or the gastroenterologist may perform Botox injections of the LES or perform balloon dilation of the LES. For more advanced disease, a Heller myotomy is performed, often with a partial fundoplication to prevent postoperative reflux disease. The Heller myotomy consists of cutting the muscular layers of the esophagus at the GE junction, leaving the inner lining (the mucosa) intact. If the disease is very advanced and the esophagus is extremely dilated (called a “megaesophagus”), an esophagectomy (removal of the esophagus) is often required.
Esophageal cancer is a malignancy of the esophagus. There are two main types, squamous cell carcinoma and adenocarcinoma. Squamous cell is often associated with smoking and alcohol consumption, and adenocarcinoma is often associated with gastroesophageal reflux disease (GERD) and Barrett’s esophagus. Difficulty swallowing (dysphagia) and painful swallowing (odynophagia) are the most common symptoms. Often it is hard to swallow bulky food, but liquids may be tolerated. Pain behind the sternum is common as are weight loss and poor appetite. The doctor usually orders a barium swallow, which often shows a defect concerning for cancer but must be definitively diagnosed by an upper endoscopy (EGD) with biopsies. Once diagnosed, other tests, such as endoscopic ultrasound, CT scan and PET scan, are performed to assess for local or distant metastasis (cancer spread).
Treatment is based on the stage of your cancer. The stage is determined by the size of your tumor and whether your tumor has spread locally to lymph nodes or surrounding structures, or to distant organs. Your oncologist, gastroenterologist and surgeon will determine your best course of treatment depending on the stage of your cancer. This typically includes surgery, with chemotherapy and radiation therapy given either before (neoadjuvant) or after (adjuvant). Surgical treatment involves removing the esophagus (called an esophagectomy), pulling the stomach up through the chest cavity and attaching it to the remaining portion of the esophagus either in the chest or the neck, and placing a feeding tube into the small intestine for feeding until you have healed and are able to eat normally. You will have incisions in your abdomen and either your neck or chest, depending on the approach your surgeon feels is best for you.
After your surgery, you will be in the hospital seven to 10 days. Approximately seven days after your surgery, a swallow study will be performed to check for a leak at the anastomosis (connection). If no leak is present, you will begin a soft diet. A dietician will go over your diet restrictions, and you will be sent home with tube feeds, which will be set up by your home health nursing provider through your feeding tube at night. The feeding tube is typically removed at your follow-up appointment with your surgeon in the clinic. Additional treatment in the form of chemotherapy and/or radiation therapy will be determined by your team of physicians, based on the final pathologic stage of your tumor from the operation.