Oesophageal surgery is complex, particularly when a patient has cancer. If the oesophagus needs to be removed, a replacement oesophagus is created from the stomach. Narrowing (stenosis) in the oesophagus which is not caused by cancer is widened with a balloon or with surgery.
Two diseases make oesophageal surgery particularly necessary. On the one hand, oesophageal cancer, in which the oesophagus has to be partly or fully removed. On the other hand, achalasia. It is a disease in which the passage from the oesophagus to the stomach is constricted. Two procedures can be used for this procedure. The stenosis is either expanded with a balloon (dilated) or repaired with a surgical procedure.
Partial or complete oesophagus removal (oesophagectomy) in patients with oesophageal cancer is an extremely complex operation. The procedure is performed in both the abdominal and in the chest cavity. Laporoscopy and thoracoscopy are the preferred methods used nowadays. Thanks to this minimally invasive approach, the procedure has become much less traumatic and the complication rate has been lowered considerably.
What preparations are carried out before the procedure?
Different examinations are used to determine the exact position and the spread of the tumour in patients with oesophageal cancer. For example, [oesophagoscopy], ultrasound examination as well as computer tomography. Oesophageal cancer is often treated with radiotherapy and chemotherapy. This improves the prognosis after the operation.
If the patient has achalasia, a pressure measurement (oesophageal manometry) is carried out before surgery.
As is standard before all operations, patients must stop taking any blood-thinning medication. The operation is performed under general anaesthetic. Patients should therefore have an empty stomach for the procedure.
How is the operation performed?
Firstly, the procedure is undertaken in the abdominal cavity. The camera and instruments are inserted via several abdominal incisions (laporoscopy). A narrow tube which functions as a replacement for the oesophagus is fashioned from the stomach. The lymph nodes in the vicinity of the stomach are systematically removed.
Then the patient is turned onto their left side for the thoroscopic part of the operation. In order to have better access to the oesophagus, the right lung flap is temporarily no longer aerated and it collapses. The camera and instruments are in turn inserted between the ribs via several incisions for the operation. The oesophagus is carefully exposed and isolate, along with the surrounding lymph nodes. Then the pre-prepared sleeve stomach is pulled up into the chest and connected with the rest of the oesophagus. Finally, the right lobe of the lung is reinflated and the skin incisions are sutured.
The examination takes between three and four hours.
The oesophagus is usually dilated with a balloon in patients with achalasia. This is inserted into the oesophagus with the help of radiological imaging and inflated in the constriction.
In cases where balloon dilation is not possible or does not produce the desired result, the constriction is surgically dilated. Then the sphincter muscle of the oesophagus is split (oesophageal myotomy), which transforms the opening disorder of the sphincter muscle into a closing disorder. Therefore, oesophagus myotomy is often combined with reflux surgery.
What is the success rate of this procedure?
The operation is the only possibility for patients with oesophagus cancer to have a chance of recovering or extending their life. The prognosis depends on the stage of the cancer. If the surgery takes place at an earlier stage, the patient may have an up to 90% chance of recovery.
In the case of the achalasia, the symptoms can be remedied with balloon dilation or surgical dilation in the majority of patients over the long term.
What are the possible complications and risks of this procedure?
The risks during removal of the oesophagus must not be underestimated. The minimal invasive operation can markedly lower lung complications in particular. Sometimes leaks can occur in the replacement oesophagus. This procedure may occasionally result in post-operative haemorrhaging, nerve damage and infections.
What happens after the operation?
After an oesophagus removal, the patient is often still respirated and monitored for several hours in the intensive care ward. They must refrain from eating and drinking for several days until the new suture seam is stable and has sealed. The function of the new oesophagus will be checked with a contrast agent examination in several days. The drainage tubes only removed if the oesophagus is definitely sealed.
The patient's food intake is slowly and carefully after the operation. Initially, only small amounts of easy-to-swallow food may be eaten. In this way, the swallowing function of the new oesophagus is trained and built up step by step.
A strict after-care programme and regular check-ups are required to observe how the disease progresses and to detect the reappearance of tumours in a timely manner.