What is Esophageal Cancer?
Esophageal cancer of the lower esophagus has increased 300-500% in the last 20 years. Adenocarcinoma which most associate with reflux and some with the increased use of Proton Pump inhibitors (Prilosec) has become the most common type of esophageal cancer in the United States. This replaces squamous cell cancer which is caused by smoking.
Symptoms of Esophageal Cancer
- Dysphagia – “food sticking in the esophagus” this tends to be progressive in nature with solids first, then softer foods, and finally liquids
- Weight loss – secondary to inability to eat or loss of appetite
- Anemia – secondary to chronic blood loss from tumor and/or malnutrition
- Choking, coughing, and aspiration – from failure of the esophagus to clear of foods/liquids resulting in irritation of the vocal cords
- Hoarseness– may be a sign of advanced disease secondary to involvement of surrounding nerves.
The initial study is an upper endoscopy, using a lighted camera and looking into the esophagus. This test is typically done with the patient under sedation and biopsies/samples of the tumor can be taken at the same time to confirm what is visualized. Once a diagnosis is made further testing is required to determine the stage or how far the tumor has progressed.
- Endoscopic ultrasound – similar to an upper endoscopy but an ultrasound probe is attached to the scope to determine thickness of the tumor, whether lymph nodes are involved, and even to guide deeper biopsies
- PET/CT scan – this is a powerful tool to detect if the tumor has spread beyond the esophagus i.e. the liver, lungs, distant lymph nodes
Esophageal Cancer Treatment
Curative treatment requires resection of the cancer and the extent of that resection is determined by the stage of the disease. This can be as minimal as removing the tumor endoscopically for very early disease to complete esophagectomy, removal of the entire esophagus and part of the stomach.
Technique for Esophagectomy
This can be done many different ways and no one option is ideal for every patient. The surgery can be approached through the chest and abdomen through either traditional or minimally invasive techniques or through the abdomen and neck using the similar approaches. The advantage of the latter is less pain, less time in the ICU, and much faster discharge and recovery. There is much debate on whether avoiding entering the chest is optimal since the lymph nodes in the chest can only be removed this way. Studies by Dr. Orringer show no increase in survival when done through the chest and an increased complication rate. It is therefore our preference to approach this through the abdomen, or transhiatal approach, whenever possible. Pictured below are the incisions after a laparoscopic transhiatal resection. One incision is in the left neck with 3, 0.5cm incisions and 2, 1cm incisions.
This is a major surgery and recovery is typically slow regardless of the approach. The most significant issue will be maintaining nutrition after surgery since part of the stomach has been removed and therefore can hold less food. This can be done with multiple small meals and liquid protein shakes and is of upmost importance to assist with healing and recovery. As with any surgery early ambulation and return to light activity is strongly encouraged, but it may be 3-4 weeks before one is able to return to work. Some patients experience reflux after surgery that can usually be treated effectively with medications.
Complications from Esophageal Cancer Surgery
- Injury to adjacent organs
- Leaks from anastomosis – This occurs when the connection between the stomach and esophagus breaks down and gastric juices leak out. This can be devastating if it occurs in the chest, but when it occurs in the neck is treated by opening the wound and draining the fluid. This will usually heal over the course of 1-2 weeks.
- Stricture – This is a late affect that is caused by scarring at the connection between the stomach and esophagus. As it scars it shrinks and can lead to difficulty swallowing. It is usually treated by dilatations done endoscopically and rarely requires repeat surgery. It also occurs more commonly if associated with a leak described above.
- GERD – For some this can be significant and more commonly if the resection and anastomosis (reconnection) is done in the chest.
Chemo and Radiation Therapy
The need for this is determined based on the stage of the cancer. If pre-operative diagnostic studies show advanced tumor then chemo and radiation therapy will be done prior to surgery. This is done to try and shrink the tumor so that complete resection of the tumor can be done at the time of surgery. If the tumor appears limited or an early stage then it may be recommended to proceed straight to surgery and post op therapy will be determined based on the stage after examining it microscopically.
Pre and Post-Operative Instructions for Laparoscopic Esophagectomy
- Discuss with your surgeon treatment options and ask any questions you might have with regards to that treatment.
- Sign consent for surgery confirming that you understand the potential risks and benefits of surgery and agree to proceed.
- Complete pre-operative testing including blood work, EKG or other tests your physician may order
- After lunch the day before surgery eat only a liquid diet and take 1 bottle of Magnesium Citrate at 2:00pm or after work. This will empty your colon making your surgery safer and decreasing issues with constipation post operatively.
- Shower with Hibiclense (anti-bacterial soap) the night before and morning of surgery to help decrease risk of wound infection. (It can be purchased at any pharmacy or may be given to you by hospital staff) 6) Do NOT eat or drink anything after midnight before surgery. The stomach needs to be completely empty prior to surgery.
- Stop Aspirin 1 week prior, Plavix 10 days prior, and Coumadin (Wafarin) 5 days prior to surgery. Notify your surgeon if taking any other blood thinners for instruction on when to stop them.
- Stop Smoking 1 week prior to surgery
Day of Surgery
- Arrive at hospital at time instructed by office staff. A minimum of 2 hours prior to scheduled surgery time
- Nurses will prepare you for surgery with an IV and any pre-op medications that have been ordered.
- The anesthesiologist will talk to you about putting you to sleep in a room just outside the operating room.
- After surgery you will go to the recovery room for about 1 hour where you will be watched closely as you continue to wake up. Family members are not allowed in at this time.
- You will spend at least 1 night in the hospital.
After Discharge from the Hospital
- You are encouraged to walk and resume light activity when you return home
- No lifting over 20 pounds until you see your surgeon.
- Take pain medications as needed to allow increased mobility.
- Prevent constipation by drinking lots of fluid and if necessary taking a stool softener (Colace) or Milk of Magnesia as needed.
- Schedule a post-operative appointment for 2 weeks after surgery. Do this the day you get home or soon thereafter for ease of scheduling.
Call Your Doctor If:
- Persistent fever over 101 degrees F
- Significant bleeding
- Pain not relieved by medications or that is getting more severe
- Persistent nausea and vomiting
- Increasing redness or drainage from the incisions
- If unable to eat or drink liquids
- Constipation not relieved by stool softeners or Milk of Magnesia of 3 days duration
- Persistent cough or increasing shortness of breath