Cancer of the Esophagus - Esophagectomy
It is a rather aggressive kind of cancer. Often it is associated with a long history of advanced esophagitis in patients with gastro-esophageal reflux disease, but this may not always be the case. One of this cancerʼs unique characteristics is that it progresses rapidly through its wall to the outside surrounding tissues and thus gives metastases rather early. This is because the wall of the esophagus is made of only 3 layers, instead of 4 in all other parts of the digestive tract (except for the rectum). Difficulty in swallowing, which gets worse with time, first with solid food and later with liquids, is the most common presenting symptom. The diagnosis is made with endoscoopy and biopsy.
The sole definitive treatment of esophageal cancer is surgery, which involves removal of the esophagus (esophagectomy), along with all the lymph nodes and the seemingly healthy tissues surrounding the esophagus. Many scientific studies have demonstrated the importance of radical lymph node dissection (removal). An esophagectomy that does not involve resection of all these lymph nodes is considered oncologically insufficient and may predispose such patients to early local recurrence or early metastasis of the cancer.
Because at the time of diagnosis, the esophageal cancer may have progressed through the wall of the esophagus into the fatty tissues around it and in the lymph nodes, this has to be well recognized before the operation. This extremely important information comes from a diagnostic modality called endoscopic ultrasonography (EUS). EUS will precisely demonstrate the true depth of wall involvement and penetration. In case of more advanced disease, it is prudent for the patient to undergo chemotherapy first, before the operation. This strategy of “neoadjuvant chemotherapy” will “downstage” the disease, or shrink it both in size, as well as in depth of wall penetration, so a subsequent operation will provide maximal radicality. More importantly, this strategy is clearly associated also with improved long term outcome, which means a lower risk of cancer recurrence, or metastasis and a longer survival.
Resection of the esophagus requires highly specialized technique. Since the esophagus traverses the whole chest and ends in the abdomen, the operation used to require two large incisions, one in the abdomen and one in the chest. This latter incision may be associated with significant complications. In patients with cancer at the lower end of the esophagus, and especially after neoadjuvant chemotherapy, esophagectomy can be performed without a chest incision, but with a small incision in the left side of the neck, in addition of course to the abdominal incision. This “transhiatal esophagectomy” has many advantages: significantly less postoperative pain, respiratory function which is not compromised, and lower risk of a significant postoperative infection. During esophagectomy, the whole esophagus is removed along with a portion of the stomach with the adjacent lymph nodes. The part of the stomach that is not removed, takes then the shape of a long tube and is connected with the cut end of the origin of the esophagus in the neck.
