Surgical resection (removal) of the esophagus is indicated in several
types of esophageal abnormalities, as well as for esophageal cancer. Your surgeon will choose one of several approaches for
the removal of your esophagus and will describe the specific approach to be used for you.
After you have received your epidural for pain control and are asleep,
the surgeon will remove the mass and form a replacement esophagus out of your stomach. The surgery will take approximately
6 hours. Additional time may be needed before surgery to insert intravenous lines and put you to sleep. The esophagus and
associated lymph nodes will be sent to pathology for analysis. The final pathology report usually takes 10 to 14 days. The
surgeon will notify you of your diagnosis as soon as he has the final report. If you have not heard from him within two weeks,
please contact the office.
Left Transthoracic (Chest) Approach
Ivor-Lewis (Belly and Right Chest)
Three Hole Esophagectomy
(Right Chest/Belly/Left Neck)
Transhiatal (No Chest Incision)
There are four currently used surgical approaches for an esophagectomy--Transthoracic,
Ivor-Lewis, 3-Hole Esophagectomy and Transhiatal. Approaches are chosen by the surgeon in order for the esophagus, tumor or
obstruction, and lymph nodes to be adequately removed. Sometimes a neck incision will need to be made instead of an abdomen
incision due to the location of the tumor.
If you have not previously had a feeding tube placed, you will have
one inserted into your small intestine during the operation. This will be used to feed you during the time you are not able
to eat by mouth. It will help keep your body in optimal condition during the postoperative period and will be removed approximately
1 month after surgery.
During surgery, one or more chest tubes will be placed into your
side. These chest tubes are used for drainage and to monitor air leakage. The tube is hooked up to an empty container, which
will collect any fluid that drains out from your chest. The chest tube will remain in until the drainage stops and there is
no air leakage.
Operations create pain. We make every effort to minimize your discomfort
through oral medications, IV medications and epidural catheters. You will be asked frequently about your pain. Please be honest.
It is very important for the pain to be under control because taking deep breaths and moving are essential for quick recovery.
- PCA (Patient Controlled Analgesia): This
is pain medicine that is given through your IV. You will be able to press a button connected to the pain medicine and dose
yourself as needed. You do not need to worry about overdosing or becoming addicted. Limits will be programmed into the pump
and you will not become dependent while you are having real pain.
- Epidural Catheter: This is a very small
tube placed in your back at the time of surgery. Pain medication is infused through the catheter, which will bathe the spinal
cord and prevent pain. You may have a PCA button for your epidural pain medicine (see above).
- Oral medications are most often given on
an "as needed" schedule. This means that you must ask the nurse to give you the medicine. Usually, there is a 4 hour interval
between doses. Please let your nurse know if you need your medicine more frequently or if it makes you too sleepy.
Deep Breathing, Coughing & Incentive Spirometry
It is very important to cough and deep breath after surgery. Your
lungs need to be fully expanded to prevent infection and collapse. Please practice coughing and deep breathing before you
come in for surgery.
- Deep breathing: fill your lungs up slowly
over a count of 5, hold for a count of 5, exhale slowly over a count of 5. REPEAT 10 TIMES per hour while you are awake.
- Coughing: take two slow breaths filling
your lungs up as much as possible. Begin your cough as you exhale the second time. Make sure you hold a pillow or towel over
your incision (also called "splinting" your incision) during your cough. This will decrease the pain. REPEAT 10 TIMES per
hour while you are awake.
- Incentive Spirometry: Hold the spirometer
securely in two hands and place your mouth on the mouth piece. Exhale around the mouth piece and make a tight seal on the
mouthpiece. Inhale slowly to the count of 5 while you watch the disc move upward. Hold for a count of 5, loosen the seal around
the mouthpiece & exhale. REPEAT 10 TIMES per hour while you are awake.
Walking and moving frequently are very important components of your
recovery. The more you push yourself to exercise and move, the quicker and less painful your recovery will be. You may not
feel up to moving, BUT YOU MUST. You will be up in the chair the night of surgery and walking in your room the next morning.
You will not be allowed to eat or drink ANYTHING for the first week
after surgery. You will have a nasogastric tube (NG tube) inserted into your nose through your new "esophagus", past the internal
incisions while you are in surgery. NO ONE except your attending surgeon should remove or reposition this tube. This tube
will be attached to suction & will drain the fluid secreted by your stomach. Your nurse will flush this tube several times
each day to keep it clear. As long as it is working properly, you should not feel nauseous or vomit. Tell your nurse if you
do feel nauseous.
- You will receive IV fluids for the first week. Any extra medicines
you need will also be given through your IV.
- You will begin feedings through the feeding tube in your abdomen
on the first or second day after surgery. The amount of these feedings will be increased slowly over the next several days.
- You will have a swallowing test within 7-14 days of your surgery.
You will be given a special liquid to drink while x-rays are taken. If there are no areas of leaking fluid on the xrays ,
your doctor will remove your NG tube and you will be allowed to take sips of clear liquids. Your diet will be increased gradually
to 6 small SOFT meals each day.
Risks & Potential Complications
Your surgeon will explain the risks and alternatives to surgery
in detail with you. It is an extensive procedure, requiring a significant about of time under general anesthesia. Every possible
precaution will be taken. The major risks of an esophagectomy are leaks from the internal suture line, pneumonia or infection,
bleeding, abnormal heart rhythms, and rarely heart attack and death.
Specific major complications in patients undergoing oesophagectomy
include respiratory failure, anastomotic leakage and delayed gastric emptying.
Atelectasis and respiratory insufficiency
These are common after transthoracic oesophagectomy. Good analgesia,
physiotherapy, appropriate hydration and early mobilisation are all essential to minimise respiratory complications.
This may occur in the early post-operative period (2-3 days) when
it is deemed due to technical failure or later (3-7 days) when it is thought more likely to be due to ischaemic changes in
the stomach, usually close to the suture line. This is associated with significant mortality and morbidity. Occasionally,
small radiologically demonstrated leaks are seen at 7-10 days but these can be clinically insignificant or associated with
little disturbance. These may be treated conservatively with confidence. Early leaks or gastric ischaemia may be associated
with profound acidosis and respiratory distress. Such signs should alert the team to the possibilities of a leak or ischaemia
and prompt early investigation, preferably by endoscopy, but contrast swallow may also be of help. Early leaks and ischaemia
should be treated aggressively by re-exploration and appropriate resection, defunctioning or re-anastomosis where appropriate.
Delayed gastric emptying
This may occur if the stomach lies redundantly in the thorax. Occasionally,
it is a consequence of an intact pylorus in a transposed stomach. This complication is best avoided by accurate positioning
of the stomach within the chest and ensuring a widely patent pylorus at the time of surgery. Any doubts about patency should
lead to the formation of a pyloroplasty. Treatment of delayed gastric emptying is directed at enhancing gastric emptying with
Metoclopramide and/or pyloric balloon dilatation