Surgery for Esophageal Cancer

This content has been reviewed and approved by

Chandra P. Belani, MD
Deputy Director, Penn State Cancer Institute
Miriam Beckner Professor of Medicine
Penn State University School of Medicine

Surgery is often an essential part of the treatment of esophageal cancer. Physicians sometimes suggest removing the esophagus (esophagectomy) to prevent esophageal cancer from occurring in high-risk individuals with Barrett's esophagus. Physicians also suggest surgery as primary treatment for early stage cancer and to reduce side effects or symptoms from the cancer in patients with extensive disease.

Primary Surgical Treatment of Esophageal Cancer

Often, surgeons can remove early cancers, stage 0 and I, through an endoscope (thin, flexible, lighted tube) if these cancers have not spread widely up or down the esophagus. However, most esophageal cancers require surgically removing a large portion of the esophagus (esophagectomy).

Esophageal cancer cannot be cured in most patients because patients usually receive their diagnosis after the cancer has spread. In addition, many patients are often too ill for aggressive surgical treatment. One of the major dilemmas facing patients with esophageal cancer is whether to undergo a major surgical procedure or to be treated with radiation therapy and chemotherapy without surgery.

Surgical Approaches

There are several surgical approaches for removing the esophagus. The important considerations are to remove all of the cancer and to restore the continuity of the normal digestive system so that patients can feed themselves without a lot of complications.

The type of surgery depends on the location of your cancer, the extent of your cancer, your overall condition, and your surgeon’s preference. The two most common methods are transhiatal esophagectomy and transthoracic esophagectomy.

Transhiatal esophagectomy - The surgeon removes the portion of the esophagus containing the cancer and reattaches the remaining esophagus to the stomach. During transhiatal esophagectomy, a surgeon makes two incisions: one in the cervical or neck region and the other in the upper abdomen. The surgeon also makes a third incision through the diaphragm, which is the breathing muscle that separates the chest from the abdomen.

Transthoracic esophagectomy - A transthoracic esophagectomy involves a single incision in the left chest and a dividing of the left part of the diaphragm. Surgeons usually explore your abdomen when they perform an operation to remove esophageal cancer. Sampling your lymph nodes can help determine your current stage of cancer.

During an esophagectomy, the surgeon removes the esophagus, pulls up the stomach to the neck region, then connects the stomach to the cut end of the remaining esophagus. Cancers of the lower esophagus are easier to treat than cancers of the upper esophagus because a longer portion of normal esophagus remains. Cancers of the upper esophagus can invade the larynx (voice box) and the pharynx (throat), making reconstruction of an adequate tube to the stomach difficult.

Complications of Esophagectomy

The major complications of surgery are pneumonia and leaking of digestive fluids at the site where the stomach is sewn into the remaining esophagus. The death rate from complications following esophagectomy varies from 0 percent to 17 percent, depending on the stage of cancer, condition of the patient, and experience of the surgical team.

If you’re planning to undergo surgery, it’s important that you receive treatment at an institution that performs a large number of esophagectomies. The reason is that the operative death rate is directly linked to the experience of the team of surgeons, anesthesiologists, and nurses performing the operation.

Surgery alone is the primary treatment for many patients with stage 0, I, or II esophageal cancers. Surgery for stage III cancer is somewhat controversial. Physicians often perform this surgery after neoadjuvant chemotherapy and radiation therapy.

Surgery in the Elderly

There are several clinical studies suggesting that advanced age alone should not prevent older patients from receiving treatment with esophagectomy. The condition of the patient and not the age should be the determining factor in pursuing an aggressive surgical approach in treating esophageal cancer.

Surgery for Palliation (Symptom Relief) of Esophageal Cancer

In situations in which your cancer is not curable, your physician often may recommend surgery to improve your ability to pass food through your esophagus.

Nutritional Support

Before any surgical procedure, you need to prepare adequately to minimize complications. Most patients with esophageal cancer are malnourished at the time of diagnosis. Although aggressive nutritional support does not usually improve long-term survival, studies show that better nutrition improves survival in the immediate postoperative period.

Physicians may enhance a patient’s nutrition before surgery by placing a nasogastric tube (a clear plastic tube that the physician inserts through the nose, down the back of the throat, through the esophagus, and into the stomach) and/or by intravenous feeding (through a vein). As discussed above, it is important to maintain an open esophagus so that patients can feed themselves. In extreme cases, a tube may be placed directly into the stomach.