Surgery is an integral part of the treatment of esophageal cancer. However, since esophageal cancer is not exclusively a surgical disease, it is important for patients to be treated at a medical center that can offer multi-modality treatment involving surgeons, gastroenterologists, radiation oncologists, medical oncologists and nutritionists.
Removal of the esophagus (esophagectomy) may be utilized to prevent esophageal cancer from occurring in high-risk individuals with Barrett’s esophagus, as primary treatment for early stage cancer and as palliation to reduce side effects or symptoms from the cancer in patients with extensive disease. The primary goal of treatment (cure vs. palliation), the experience of the surgical team and the age of the patient should all be considered when making a decision about esophagectomy.
Barrett’s Esophageal With or Without Low-Grade Dysplasia
Surgery vs. Medical Management
Surgical management of patients with Barrett’s esophagus with or without low-grade dysplasia is directed at preventing reflux of stomach contents into the esophagus.
There is evidence that surgical prevention of reflux of stomach contents can prevent the progression of Barrett’s esophagus and may prevent progression to dysplasia. One clinical study demonstrated a decrease in columnar epithelium and low-grade dysplastic changes after anti-reflux surgery. In another study involving surveillance of patients with Barrett’s esophagus, none of the patients who had received anti-reflux surgery developed dysplasia.
These and other studies suggest that anti-reflux surgery can reduce symptoms and prevent progression to dysplasia. Long-term endoscopic follow-up is still required in all patients with Barrett’s esophagus after anti-reflux surgery because it is still unknown if this treatment prevents progression to cancer.
The usual anti-reflux procedure (fundoplication) is a simple operation that does not involve cutting open the stomach or esophagus. The surgeon sews together the upper and middle parts of the stomach to prevent portions of the upper stomach from protruding above the diaphragm. This usually prevents reflux of stomach contents into the esophagus. Fundoplication can be performed through an incision in the left upper abdomen or through a laparoscope (a lighted flexible tube inserted through a small cut in the abdomen). One randomized clinical trial directly comparing the laparoscopy approach to the standard incision in the left upper abdomen demonstrated that the open operation was superior to the laparoscopic surgery for the prevention of reflux. Patient’s considering treatment with the laparoscopic procedure should inquire as to the success rate of the surgeon.
Barrett’s Esophagus with High-Grade Dysplasia
Several studies have clearly demonstrated that patients who have been diagnosed with high-grade dysplasia on endoscopic biopsy actually have a 40-50% chance of having invasive adenocarcinoma of the esophagus. In one study, one-third of patients who underwent esophagectomy for high-grade dysplasia with Barrett’s esophagus had stage I-III adenocarcinoma of the esophagus and approximately one-sixth of these patients ultimately died of adenocarcinoma. There were no deaths from cancer in patients who only had high-grade dysplasia. In a review of 85 patients who had esophagectomy as treatment for high-grade dysplasia, 41% had adenocarcinoma in the removed esophagus. These results highlight the unreliability of endoscopic biopsy in detecting early invasive cancer in patients with high-grade dysplasia of the lower esophagus in association with Barrett’s esophagus. The cure rate from surgery for high-grade dysplasia is over 90% and the cure rate for the 40-50% with adenocarcinoma depends on the stage of cancer. Esophagectomy currently appears to be the treatment of choice for patients with high-grade dysplasia occurring in Barrett’s esophagus.
Primary Surgical Treatment of Cancer of the Esophagus
Early cancers, stage 0 and I, can often be removed through an endoscope if they have not spread widely up or down the esophagus. However, the overwhelming majority of esophageal cancers require surgical removal of a large portion of the esophagus (esophagectomy).
Esophageal cancer cannot be cured in the majority of patients because the diagnosis is usually made 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 or not to undergo a major surgical procedure or to be treated with radiation therapy and chemotherapy without surgery.
There are several approaches to the surgical removal of 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 excessive complications or death resulting from the surgery itself. The choice of type of surgery depends on the location of the cancer, extent of cancer, condition of the patient and the preference of the surgeon. Currently, 2 methods predominate: trans-hiatal esophagectomy and trans-thoracic esophagectomy. During an esophagectomy, the surgeon removes the portion of the esophagus containing the cancer and reattaches the remaining esophagus to the stomach.
During trans-hiatal esophagectomy, a surgeon makes two incisions, one in the cervical or neck region and the other in the upper abdomen. A third incision is made through the diaphragm, which is the breathing muscle that separates the chest from the abdomen. In contrast, a trans-thoracic esophagectomy involves a single incision in the left chest, with division of the left part of the diaphragm.
Surgical exploration of the abdomen is usually performed during all operations for removal of esophageal cancer. The sampling of lymph nodes can help determine the current stage of cancer and whether the goal of treatment is to be curative or palliative. During an esophagectomy, the esophagus is removed and then the stomach is pulled up to the neck region and is connected 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 0-17%, depending on the stage of cancer, condition of the patient and experience of the surgical team. It is important that patients planning to undergo surgery receive treatment at an institution that performs a large number of esophagectomies because the operative death rate is directly linked to the experience of the team of surgeons, anesthesiologists and nurses performing the operation. A recent clinical study evaluated deaths occurring in the first 30 days after esophagectomy in over 5,000 patients treated at various medical institutions. Following esophagectomy, 17% of patients died in hospitals that performed a few esophagectomies per year, compared to 3.4% in hospitals that performed many esophagectomies per year. This difference is even more revealing since larger centers often treat the more difficult cases. Patients should request information concerning the success and complication rates of the surgical team performing the esophagectomy at the institution where the operation is planned.
Surgery alone is the primary treatment for many patients with stage 0, I, or II esophageal cancers and results are detailed in the treatment overview sections. For more information, go to Stage 0 cancer, Stage I cancer, Stage II cancer.
Surgery for stage III cancer is somewhat controversial and is often performed after neoadjuvant chemotherapy and radiation therapy. For more information, go to Stage III cancer.
Extent of Surgery
There is currently some controversy over the extent of surgery required to eliminate all cancer in patients who have spread of cancer outside the esophagus. Some surgeons, especially in Japan, claim that survival is improved if extensive surgery is utilized to remove all of the involved lymph nodes. This is sometimes accomplished with three different surgical incisions. In general, the more extensive the surgery, the higher the complication and death rate. Some surgeons claim that less extensive surgery is acceptable. Unfortunately, no clinical trials have been performed that to directly compare more extensive surgery with less extensive surgery. In the United States, patients are more likely to be treated with chemotherapy and radiation therapy alone or before surgery (neoadjuvant therapy) and are less likely to be treated with more extensive surgery. In fact, some surgeons who have removed the esophagus through endoscopic techniques without a major surgical incision advocate minimal surgery.
Surgery in the Elderly
There are several clinical studies that suggest that advanced age alone should not preclude older patients from being treated with esophagectomy. These studies have evaluated and reported outcomes following esophagectomy in patients 70 years of age or older. In one clinical study, the in-hospital death rate was 18% for older patients and 14% for younger patients. In another study, survival at 5 years was 24% for elderly patients and 22% for younger patients. The condition of the patient and not the age should be the determining factor in pursuing an aggressive surgical approach for treatment of esophageal cancer.
Surgery for Palliation of Cancer of the Esophagus
In situations where the cancer cannot be cured, surgery is frequently utilized to improve the ability of patients to pass food through the esophagus. In one clinical study, doctors compared the outcomes of 39 patients with stage IV esophageal cancer who underwent an esophagectomy for palliation with the outcomes of 49 patients with stage IV esophageal cancer who underwent more complete removal of cancer. Both groups of patients experienced significant improvement with regard to both the quantity and quality of food intake and a reduction in the severity of eating related symptoms. After 9 months, patients in the palliative group experienced more pain and a poorer quality of life, but there were no differences in sleep, leisure activity and performance scores when compared to the other group. This study suggests that palliative esophagectomy relieves symptoms in the majority of patients with inoperable esophageal cancer. It could also be argued that both groups had palliative surgery since the majority of patients who undergo surgery with curative intent have rapid recurrence of cancer in the first year or two after surgery.
Prior to any surgical procedure, adequate preparation of the patient is important to minimize complications. Most patients with esophageal cancer are malnourished at the time of diagnosis. Aggressive nutritional support has not been shown to improve long-term survival, but it has been shown to improve survival in the immediate post-operative period. Nutrition before surgery can be enhanced by feeding through a naso-gastric tube and/or intravenous feeding. As discussed above it is important to maintain an open esophagus so that patients can feed themselves. In extreme cases, placement of a tube directly into the stomach is justified. To learn more, go to Supportive Care.