What Is An Esophagectomy?
Surgical removal of the lower two-thirds of the esophagus (food pipe) followed by reconnecting the remaining esophagus with the stomach is known as esophagectomy. It is done in patients with esophageal cancer, non-responsive benign esophageal tumors, and end-stage achalasia (a nerve disorder that makes it difficult for food and liquids to pass through the food pipe).
In these patients, the esophageal functions deteriorate to the point where it is no longer possible to swallow.
What Causes the Esophagus to Deteriorate?
The digestive system starts with the mouth, followed by the pharynx, the esophagus, the stomach, the large and small intestine, the rectum, and the anus. In the context of esophagectomy, the term food pipe will be used for the esophagus.
The esophagus is a muscular channel with two sphincters on either end a) upper esophageal sphincter (UES) and b) lower esophageal sphincter (LES). Food travels from UES to LES through muscular contractions in the food pipe known as peristalsis.
If there is a problem in the food pipe, the patient will be able to experience it in the form of dysphagia (difficulty in swallowing). Now dysphagia can occur in two ways-
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Difficulty in initiating a swallow which is due to problems in the mouth and pharynx.
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Difficulty in actually swallowing is an esophageal disorder and is named esophageal dysphagia.
The esophageal dysphagia will occur due to physical obstruction or problems in the nerves that control the esophagus (motor disorder). Different conditions which cause physical obstruction and motor dysfunction are mentioned below-
1) Physical Obstruction Dysphagia- Conditions that cause difficulty in swallowing by obstructing the food pipe are-
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Esophageal Carcinoma- Usually caused by squamous cell carcinomas or adenocarcinomas. Cancer narrows the lumen of the esophagus leading to dysphagia. Upper endoscopy and biopsy will confirm the diagnosis of esophageal cancer.
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Reflux Esophagitis- Inflammation of the esophagus due to backward flow of stomach acid causes reflux esophagitis. This inflammation narrows the food pipe, thereby physically obstructing the food.
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Peptic Strictures- It is a long-term consequence of reflux esophagitis. The inflammation continues leading to scarring and further narrowing. Barium swallow studies and upper endoscopy will confirm the diagnosis.
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Schatski’s Rings- The esophagus is a muscle that is lined with mucosa, which is a moist membrane. Patients with Schatski’s ring have a band of excessive mucosa over the normal esophageal mucosa leading to the decreased lumen and causing dysphagia. This condition is often associated with hernias and can be diagnosed with esophagogastroduodenoscopy (EGD) or barium swallow studies.
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Zenkers’ Diverticulum- As mentioned before, the esophagus has sphincters on either end. The UES will need to relax for the incoming food to pass through the food pipe; this relaxing function is debilitated in patients with Zenker’s Diverticulum. When the pharynx is excessively pressured, the weakest portion of the pharyngeal wall will balloon out, causing a chain of events that will ultimately reduce the relaxation of UES, leading to dysphagia and food regurgitation, and bad breath.
2. Motor Dysfunction Dysphagia- The esophagus is essentially a muscle; it is controlled by the brain through the nerves; any abnormalities in these structures will cause dysphagia. Some of them are-
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Diffuse Esophageal Spasm- In this condition, the esophageal contractions which are supposed to move food from the UES to the LES become irregular and uncoordinated, leading to dysphagia and chest pain. An X-ray will show the characteristic cork-screw or rosary bead appearance of the esophagus, and a manometry will reveal episodes of dysfunctional peristalsis (muscle contractions).
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Achalasia- Ideally, after normal peristalsis, the food will reach the lower esophageal sphincter, which relaxes, allowing the food to pass to the stomach. In patients with achalasia, the LES of the food pipe fails to relax due to the loss of inhibitory nerve fiber signals leading to dysphagia. Barium swallow studies will reveal the classical bird-beak deformity, and a manometry will confirm the diagnosis.
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Scleroderma- It is an inflammatory auto-immune disease that replaces the normal tissue with fibrous tissue and collagen. It usually affects the skin and gastrointestinal tract, especially the esophagus. Fibrosis of the smooth muscle in the esophagus reduces its mobility and impairs the function of LES leading to dysphagia and heartburn. Manometry will confirm the diagnosis.
Apart from the above-mentioned conditions, any chronic condition that leads to peripheral neuropathy (like diabetes mellitus) can also cause dysphagia of esophageal origin. Treating the underlying conditions along with speech-language therapy can help to a certain extent but is not possible for all of them, which leaves esophagectomy as the only option.
How Is An Esophagectomy Done?
After careful evaluation and confirming the pathology (cause of the disease), the clinician will request investigations like a computed tomographic (CT) scan, magnetic resonance imaging (MRI), positron emission tomography (PET) imaging, and endoscopic ultrasound-guided fine-needle biopsy. These Investigations understand the anatomy and determine the type of procedure suited for the individual patient.
Depending on the patient factors and the tumor location (in the case of esophageal cancer), the surgeon will choose from one of the below options-
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Ivor Lewis Esophagectomy- Also known as open esophagectomy, the surgeon makes large incisions in the neck, chest, or abdomen after anesthetization. If the incisions are made in the neck and abdomen, it is known as transhiatal esophagectomy, and if the main incisions are made in the chest and abdomen, it is called transthoracic esophagectomy. After the incisions, the abdomen is explored, and the tumor is sought out if the procedure is done for cancer. Care is taken to protect the gastric arteries and vessels, and with the help of surgical instruments, the distal end (lower two-thirds) of the esophagus and stomach is freed from the surrounding tissues. The esophagus is encircled and dissected bluntly, and a gastric tube is created by stapling the remaining esophagus to the stomach by pulling the topmost part of the stomach through the diaphragm.
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Minimally Invasive Esophagectomy- Although the underlying technology to remove the affected esophagus remains the same, the minimally-invasive esophagectomy uses a laparoscope (camera-tipped device) to view and perform the operation.
After the procedure, the surgeon will place a feeding tube directly into the stomach that will ensure adequate nutrition while the patient recovers. The tube will be removed after four to six weeks, after which the patient will be able to resume a normal diet. Because the stomach’s size is reduced due to stretching, the patient will have to eat more frequently in lesser quantities.
What Are the Complications of Esophagectomy?
Esophagectomy is a serious surgery performed to treat life-threatening conditions; risks are part and parcel of the procedure. The frequently seen complications are-
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Bleeding and pneumonia.
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Food and gastric juice leakage at the junction where the esophagus and stomach are joined.
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Possible infection through the incisions.
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Lymphatic leakage due to the injury to the underlying thoracic duct.
What Happens After Esophagectomy?
Post-operatively the patient is instructed on wound care and nutrition; the hospital staff will guide the patient through the transition phase from tube feeding to oral feeding. The patient will be advised to check the incision regularly for signs of infection, swelling, bleeding, and draining.
Conclusion:
Esophagectomy drastically improves the quality of life by helping the patients swallow and nurture themself. If the procedure is done because of cancer, the clinician might suggest additional chemo and radiation therapy. With few adjustments to the lifestyle, the patient will be able to fully recover after the procedure.
