What is an esophageal resection operation?

Esophageal Resection Operation: Overview

Esophageal resection (esophagectomy) is a major surgical procedure primarily indicated for resectable esophageal and esophagogastric junction cancers, performed with curative intent in physiologically fit patients with localized disease. 1, 2

Indications

• Primary indication: Resectable esophageal and esophagogastric junction (EGJ) cancers (T1-T3 tumors)
• Secondary indications:
  • Salvage therapy for localized, resectable recurrence after definitive chemoradiation
  • End-stage benign esophageal conditions (e.g., achalasia with megaesophagus)
  • Component of palliative care in select cases

Preoperative Assessment and Preparation

• Comprehensive staging workup:

  • Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) if indicated
  • Chest and abdomen CT scan
  • PET scan (integrated PET/CT preferred) 1
  • Laparoscopy for evaluation of resectability in patients with large EGJ tumors 1

• Patient selection criteria:

  • Physiologic fitness for general anesthesia and major surgery
  • Nutritional optimization (jejunostomy feeding tube preferred over gastrostomy tube) 1, 2
  • Multidisciplinary evaluation for patients with potentially resectable disease 1

Surgical Approaches

Open Surgical Techniques

1. Ivor Lewis Esophagectomy 1, 2

   • Right thoracotomy and laparotomy
   • Upper thoracic esophagogastric anastomosis
   • Preferred for distal esophageal and EGJ tumors

2. McKeown Esophagectomy 1, 2

   • Right thoracotomy, laparotomy, and cervical anastomosis
   • Suitable for mid and upper esophageal tumors

3. Transhiatal Esophagectomy 1, 2

   • Abdominal and left cervical incisions without thoracotomy
   • May be used for frail patients with distal tumors
   • Limited lymphadenectomy compared to transthoracic approaches

Minimally Invasive Approaches

• Minimally Invasive Esophagectomy (MIE) 1
  • Includes laparoscopic, thoracoscopic, and robotic techniques
  • Benefits: lower post-operative morbidity, quicker recovery, better quality of life 1
  • May be particularly beneficial for older patients 1
  • Still considered evolving but with promising outcomes

Key Surgical Steps

1. Mobilization of the stomach 2

   • Preservation of blood supply (gastroepiploic and right gastric arteries)
   • Dissection of celiac and left gastric lymph nodes
   • Division of left gastric artery

2. Gastric conduit formation 2

   • Division along greater curvature
   • Preservation of right gastroepiploic arcade

3. Esophageal resection

   • Division above tumor level with adequate margins
   • En bloc lymphadenectomy (at least 15 lymph nodes should be removed) 1, 2

4. Reconstruction

   • Gastric conduit is preferred for reconstruction 1
   • Colon interposition reserved for patients with previous gastric surgery 1
   • Anastomosis can be thoracic or cervical

Postoperative Care

• Early enteral nutrition via jejunostomy (within 24-48 hours) 2
• Gradual introduction of oral nutrition as pain diminishes
• Monitoring for complications:
  • Anastomotic leak (should not exceed 5%)
  • Pulmonary complications
  • Wound infections
  • Stricture formation

Outcomes and Prognosis

• Curative (R0) resection rates should exceed 30% 2
• In-hospital mortality should be less than 10% 2
• The number of lymph nodes removed is an independent predictor of survival 1
• Overall 5-year survival remains challenging at less than 25% 3

Special Considerations

• For early-stage cancers (T1a), endoscopic therapy is now preferred over esophagectomy 2
• Preoperative chemoradiation or perioperative chemotherapy significantly improves survival in patients with resectable disease 1
• Open surgery remains standard for many patients, particularly those with:
  • Previous abdominal surgery
  • Large and bulky tumors
  • Concerns about gastric conduit viability
  • Difficulty with lymph node dissection 1

Esophagectomy remains a complex procedure with significant morbidity, but advancements in surgical techniques, perioperative care, and multimodality treatment approaches have improved outcomes for patients with esophageal cancer.