Esophageal Cancer: Surgery

When might surgery be used for esophageal cancer?

Surgery is often used to treat small (early stage) esophageal cancers that are in the lower part of the esophagus. It’s often used along with other treatments, like radiation therapy and chemotherapy. 

Types of surgery for esophageal cancer

Esophagectomy/esophagogastrectomy

The main surgery used to treat this type of cancer is esophagectomy. This surgery removes part or all of the esophagus. Nearby lymph nodes might also be taken out and checked for cancer. For tumors in the lower part of the esophagus, some of the stomach might also be removed. This is called an esophagogastrectomy. The pieces of the esophagus or stomach that are left are then reconnected. If there isn’t enough esophagus left to reconnect the ends, a section of intestine might be used to make the connection.

This type of surgery can be done in two ways:

• Open surgery. The surgeon makes cuts in your neck, chest, or abdomen (belly) to remove the esophagus. Where the cuts are made depends on where the cancer is in the esophagus.

• Laparoscopic surgery. For smaller tumors, the surgeon may be able to operate through smaller cuts. A flexible tube with a tiny camera on the end (called a laparoscope) is put in one cut to see inside your body. Long, thin surgical tools are put in the other cuts to do the surgery. Because the cuts are smaller, people may recover more quickly. 

Both approaches are complex. You may need a long hospital stay. It’s important that the surgeon has a lot of experience.

Palliative surgery

For cancers that are big or have spread, other surgery may be done. In this case, surgery is not done to treat the cancer, but it is used to treat problems it's causing. This is called palliative surgery. It can help with problems like trouble eating.

For instance, surgery may be done to put a feeding tube through your skin and into your stomach or small intestine. Or an expandable metal tube (stent) might be put into your esophagus. This helps keep the esophagus open so food can pass through.

Possible risks, complications, and side effects of surgery

All surgery has risks. Some of these risks include:

• Reactions to anesthesia

• Pain

• Heavy bleeding

• Infection

• Blood clots in your legs or lungs

• Damage to nearby organs

Risks from esophageal surgery

Along with the risks above, esophageal surgery can sometimes cause other problems. These can include:

• Pneumonia. Lung problems are common after surgery. This can lead to pneumonia.

• Anastomotic leak. After the surgeon removes a part of the esophagus, or the esophagus and stomach, the two ends are reconnected. This is called an anastomosis. A leak can occur at this connection. More surgery might be needed to fix this.

• Esophageal stricture.  The part of the esophagus that's attached to the stomach might become narrower. This can cause problems swallowing. Other procedures might be needed to stretch the tight area.

• Nausea and vomiting. Sometimes the nerves that help move food through the stomach are damaged during surgery. If the stomach empties slowly, it can cause nausea and vomiting.

• Heartburn. After surgery, contents from your stomach might back up into your esophagus more easily. This could lead to heartburn. Antacids or other medicines can help.

Getting ready for your surgery

Before you go for surgery, you’ll meet with your surgeon to talk about the details. Be sure to ask any questions and share concerns you may have. This is also a good time to review the side effects of the surgery and talk about its risks. You might ask if the surgery will leave scars and what those scars will look like. You might also want to ask when you can expect to eat, be up and about, or return to your normal activities. After you have discussed all the details with the surgeon, you’ll sign a consent form that says that the surgeon can do the surgery.

A few days before your surgery, your healthcare provider might give you laxatives and enemas to help clean out your colon. You'll be told when and how to use them. You may also be told to follow a special diet.

On the day of your surgery, you'll be scheduled to arrive at the hospital admission area a couple of hours before the time your surgery is set to start. You'll complete the needed paperwork and go to a pre-op area. There, you’ll undress and put on a hospital gown. A nurse will put an IV (intravenous) line into your arm. This needs just a small skin prick.

During this time, your healthcare team will ask you again about your health history. They’ll also ask about any allergies you have and the medicines you take. They will also talk about the procedure. Try not to get frustrated by the repetition. These questions are repeated to help prevent mistakes.

While you’re in the pre-op area, an anesthesiologist or a nurse anesthetist will also see you. This healthcare provider will explain the medicines (anesthesia) that will be used during your surgery. The purpose of the anesthesia is to put you to sleep so that you won't feel any pain. Answer all the questions thoroughly and honestly. This will help prevent complications. Also ask any questions you have about anesthesia. You'll sign a form that says you understand the risks involved.

Your surgeon will also see you in the pre-op area. You can ask any last-minute questions you have. This may help put your mind at ease.

What to expect during surgery

When it’s time for your surgery, you’ll be taken into the operating room. Many healthcare providers will be there. These include the anesthesiologist, surgeon, and nurses. Everyone will be wearing a surgical gown and a face mask. Once in the room, you'll be moved onto the operating table. Someone will put special stockings on your legs to help prevent blood clots. ECG wires will be put on your chest with small, sticky pads. This is done to keep track of your heart. You’ll also have a blood pressure cuff wrapped around your arm. When everything is ready, you’ll get the anesthesia through your IV and will fall asleep.

During surgery, the team may put a Foley catheter through your urethra and into your bladder. This is a soft, hollow tube used to drain urine into a bag. A breathing tube will be put in your windpipe. A breathing machine (ventilator) will control your breathing. A nasogastric tube may be put in through your nose. This is a suction tube that goes through the esophagus and into your stomach to drain stomach contents. 

What's removed during surgery and where the incisions (cuts) are depend on where the tumor is and the type of surgery you have.

After your surgery is done, you'll be moved to a recovery room. There, you'll be closely watched for another hour or so. When you wake up, don't be alarmed by the number of tubes and wires attached to you. These are normal after surgery. When you’re fully awake in the recovery room, your family might be able to see you for a short time. Once you’re awake and stable, you'll be moved to a regular hospital room.

What to expect after surgery

When you first wake up, you might have some pain. Your nurse will give you pain relievers as needed. These can help you feel more comfortable. The pain medicines will also help you get up, take deep breaths, cough, and walk after surgery. This is important for your recovery.

It will take time to get back to eating normally and having regular bowel movements. You'll have the Foley catheter in your bladder to drain urine for a few days. It allows your healthcare providers to measure your urine output and keep track of your fluid status. It’s taken out before you go home.

How long you stay in the hospital depends on the type of surgery you have. People who have a laparoscopic esophagectomy can often go home sooner. This is because they have smaller incisions that tend to heal faster.

You can slowly return to most normal activities once you leave the hospital. But don't lift anything heavy for several weeks. Always follow the instructions you get from your healthcare team.

After surgery, you may feel weak or tired for a while. This is normal. The amount of time it takes to heal and recover is different for each person. You may not feel like yourself for several months.

Your healthcare providers will give you instructions about whether and when you can get your incisions wet. You likely won't be able to drive for a while. Be sure you understand all the instructions you get from your healthcare providers. Also be sure you have follow-up appointments scheduled.

When to call your healthcare provider

Call your healthcare provider right away if you any of the following occur:

• Fever of 100.4°F (38°C) or higher, or as directed by your healthcare provider

• Chills

• Signs of infection around the incisions, such as redness, drainage, warmth, and pain

• Incision opens up or the edges pull apart

• Rapid, irregular heartbeat or new chest pain

• Increasing pain in or around your incisions

• Shortness of breath or trouble breathing

• Trouble passing urine or changes in how your urine looks or smells

• Pain, redness, swelling, or warmth in an arm or leg

Know what problems to watch for and when you need to call your healthcare providers. Also know what number to call after office hours and on weekends and holidays.