Surgical Procedures: Surgery and Staging for Esophageal Cancer

Cancerous cells in the esophagus are called esophageal cancer. The esophagus is found behind the trachea (windpipe). It is a hollow, muscular tube that connects the throat to the stomach. It helps move food from the mouth to the stomach.

Often, esophageal cancers start in the inner lining of the esophagus, or mucosa, and are either squamous cell carcinoma or adenocarcinoma. Other types of esophageal cancers include:

• Lymphomas.
• Melanomas.
• Sarcomas.
• Choriocarcinoma.
• Small cell carcinoma.

What is staging and how is it performed?

Staging is a way to find out if and where the cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. For esophagus cancers, these tests may be:

Physical Exam: This is a general exam to look at your body and to talk about past health issues. An oral cavity exam may be done by a provider or dentist.

Imaging: Radiology tests can look inside your body at the cancer and see if it has spread. These tests can include: 

• Chest X-Ray. 
• CAT scan (CT scan). 
• Positron emission tomography scan (PET scan). 
• Magnetic resonance imaging (MRI). 
• Endoscopic ultrasound (EUS).

Procedures: Each case of esophageal cancer is different. Talk with your care team about which procedures may be part of your treatment plan. These options may include:

• Barium Swallow: A barium swallow (upper GI series) uses a barium liquid to coat the esophagus and stomach. X-rays are then taken to look for any abnormal areas.
• Esophagoscopy: An esophagoscope (a lighted video tube) is inserted through the mouth or nose into the esophagus for a better view of the esophagus. Biopsies may be done during the procedure.
• Upper Endoscopy: Similar to the esophagoscopy, but also looks at the stomach. 
• Biopsy: A biopsy takes cells from the cancer, or a piece of the cancer, to see what type of cancer it is and how it behaves. A doctor called a pathologist looks at the sample in a laboratory.

Esophageal cancer spreads to other parts of the body through the tissue, lymph, and blood systems. Cancer stage determines how extensive the cancer is, how far it has spread and what treatment course will be recommended. Esophageal cancer is described as stages 0 (High-grade dysplasia) through stage IV disease. In addition, grades 1 through 3 describe how abnormal the cancer cells are.

Surgical Procedures to Treat Esophageal Cancer

Surgery is often used to treat esophageal cancers. The procedure you might have depends on many factors, including the size and location of the cancer. Your care team will talk to you about your specific procedure. 

Surgical procedures used to treat esophageal cancer include:

Esophagectomy: Removal of part or all of the esophagus. Part of the stomach may also be removed. How much of the esophagus is removed depends on many factors, including tumor stage and location. At times, the upper portion of the esophagus is connected to the stomach. In this case, part of the stomach acts as the esophagus and is pulled up into the chest or neck area.

In some cases, a stent will be placed in the esophagus to keep it open.

There are two ways to do an esophagectomy:

• Open: A surgeon will make incisions (cuts) in the abdomen (belly) and chest (transthoracic esophagectomy), the abdomen and neck (transhiatal esophagectomy), or through an incision in the neck, chest, and abdomen.

• Minimally Invasive: Many small incisions are made, and a scope and other tools are inserted into the small incisions. This can be used in some cases of early or small cancers. 

Endoscopic Resection: An endoscope (tube with a light and tools attached to it) may be inserted through the skin or through an opening, such as the mouth, to remove tissue.

Thoroscopy: An incision is made between the ribs and a lighted video tube is inserted to look at the organs in the chest. During the procedure, tissue, lymph node samples and/or removal of a portion of the lung or esophagus may be done.

Laparoscopy: A laparoscope (tube with a light and tools attached to it) is inserted through a small belly incision to look in the abdominal cavity for the presence of cancer. Organs and tissue samples can be removed as well. 

After surgery for esophageal cancer, you may need to have a feeding tube placed to provide nutritional support while you recover from surgery. 

What are the risks associated with esophageal surgery?

As with any surgery, there are risks and possible side effects. These can be:

• Reaction to anesthesia (anesthesia is the medication you are given to help you sleep through the surgery, to not remember it, and to manage pain. Reactions can include wheezing, rash, swelling and low blood pressure).
• Pneumonia.
• Bleeding.
• Blood clots.
• Infection.
• Voice changes.
• A leak at the areas where the stomach or intestine connects to the esophagus.
• Narrowing of the esophagus that can lead to trouble swallowing.
• Heartburn, nausea, and/or vomiting.
• Dumping syndrome (when food moves too quickly from the stomach to the small intestine which can cause nausea, feeling of fullness and diarrhea).

What is recovery like?

Recovery from esophageal cancer surgery will depend on the type of procedure you have had. At times, a long hospital stay is needed.

You will be taught how to care for your incisions and feeding tube, if needed, before leaving the hospital. You will learn how to change your diet if needed.

Your medical team will discuss with you the medications you will be taking, such as those for pain and blood clot prevention and/or other conditions.

Your team will talk to you about activity restrictions, which depend on the surgery you have had.

Common instructions after an esophagectomy include:

• Do not lift anything heavy. 
• Walking often. 
• Stop any activity that causes pain.
• When coughing or sneezing, you should press a pillow over any large incisions.

Contact your healthcare team if you experience:

• Fever. Your team will tell you at what temperature they should be contacted. 
• Bleeding, redness, warmth, drainage or other signs of infection at the incision. 
• Any new or worsening pain. 
• Difficulty breathing and/or a persistent cough.
• Trouble eating or drinking and/or if you are vomiting after meals.
• Diarrhea or loose bowel movements.
• Yellowing of the whites of the eyes (jaundice). 
• Throat burning with lying or sleeping.
• Symptoms of dumping syndrome, such as stomach discomfort, cramping, lightheadedness, dizziness, nausea, or diarrhea within 20 minutes of eating a meal, sweating and/or rapid heartbeat.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that you can go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation. 

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.