Esophageal Cancer Surgery

Esophageal cancer surgery is a complex surgical procedure involving the removal of the cancerous segment of the esophagus and reconstruction of the digestive tract. It is performed with curative intent in early stages and is generally carried out through a procedure called esophagectomy.

Suitability for surgery and preoperative evaluation are determined according to the stage of the disease, the patient’s general condition, and respiratory and cardiac functions. The spread of the tumor is assessed with methods such as endoscopy, PET-CT, and EUS. In some cases, neoadjuvant treatment is planned before surgery.

Surgical techniques and application methods vary according to the location of the tumor and may include transthoracic, transhiatal, or minimally invasive surgery. The stomach, colon, or small bowel segment can be used as a new esophagus. The success of the surgery requires an experienced team.

Postoperative care and possible complications include intensive care follow-up, nutritional adjustments, and management of infection risks. Problems such as anastomotic leakage, respiratory complications, and late swallowing difficulties may occur. Long-term follow-up and rehabilitation are important.

What Is Esophageal Cancer Surgery?

Esophageal cancer surgery is the surgical removal of the malignant tumor developing in the esophagus together with the surrounding lymph nodes. It is generally performed with curative intent in early and localized stages. During the operation, the diseased segment is removed and digestive continuity is restored using the stomach or intestinal tissue. In most patients, it is combined with chemotherapy and/or radiotherapy. The treatment plan is determined according to the stage of the tumor and the patient’s general condition.

What are the symptoms of esophageal cancer?

Unfortunately, the disease progresses quite silently in its early stages. Since the esophagus has a flexible structure, the patient may not feel much until the tumor grows and significantly narrows the diameter of the esophagus. Patients usually come to us with the complaint, “Food gets stuck in my throat.” This feeling of obstruction, which initially occurs with solid foods, may over time also develop with liquids.

Reading the signals your body gives correctly is vital for early diagnosis. We can list the most common symptoms of this disease as follows:

• A feeling of food getting stuck while swallowing solid foods
• Unintentional and rapid weight loss
• Burning or pain behind the breastbone
• Persistent pain radiating to the back
• Persistent hoarseness
• Food coming back into the mouth
• Persistent coughing fits
• Anemia and fatigue

If you have several of these symptoms, do not panic immediately, but be sure to consult a specialist. Especially difficulty swallowing is an alarm sign that should never be ignored.

How is esophageal cancer diagnosed?

When a patient presents to us, the first procedure we generally perform is endoscopy. With a thin tube with a lighted camera at the tip, the inside of the esophagus is examined in detail through the mouth. During this procedure, small tissue samples, that is biopsies, are taken from suspicious areas. When the result from the pathology laboratory confirms cancer, the second stage begins for us: staging.

Simply saying “there is cancer” is not enough for treatment planning. We must know “where the enemy is, how large it is, and whether it has spread elsewhere.” For this, we use advanced imaging methods.

The main methods we use in the diagnostic process are:

• Endoscopy
• Biopsy
• Computed Tomography
• PET-CT scan
• Endoscopic Ultrasonography

Sometimes we also perform barium imaging studies for our patients. In this test, the patient drinks a barium-containing liquid resembling chalky water, and an X-ray is taken. This liquid coats the inner surface of the esophagus and shows us the location and length of narrowings like a map. The purpose of all these tests is to decide whether the tumor is “resectable.” If the tumor is attached to vital structures such as the aorta or spine, or if it has spread to distant organs, then treatments other than direct surgery come to the forefront.

What is the preoperative preparation process like for esophageal cancer surgery?

Once we decide on surgery, an intensive preparation period awaits our patients. This operation is one of the largest surgical procedures performed on the body, and the body needs to be ready for it. Patients who smoke must stop smoking immediately. Breathing exercises are started to increase lung capacity. We support patients who have lost a lot of weight and whose nutritional status is poor with special nutritional supplements so they can go into surgery stronger.

In addition, today we often apply an approach called “neoadjuvant treatment.” If the tumor exceeds a certain size or if there are suspicious enlargements in the surrounding lymph nodes, chemotherapy and radiotherapy are administered before surgery.

The aims of this pre-treatment are:

• To shrink the tumor
• To achieve clear surgical margins
• To eliminate microscopic spread
• To reduce the risk of recurrence
• To prolong survival time

Approximately 6 to 8 weeks after this treatment is completed, when the body has recovered, the actual surgical procedure is performed. This waiting period is necessary for the effects of radiotherapy on tissues to settle and for the patient to regain strength.

What are the differences between open and minimally invasive esophageal cancer surgery?

In past years, these surgeries were performed with very large incisions in the chest and abdomen. This caused severe postoperative pain and prolonged the recovery process. However, with the development of technology, “Minimally Invasive Esophagectomy,” in other words closed techniques, has now come to the forefront.

In minimally invasive operations, instead of large incisions, we enter through small openings in the body with a camera and special instruments. The surgeon performs the procedure while watching the internal view on a large screen. The greatest advantage of this method is that the integrity of the patient’s chest wall is not disrupted.

The advantages of minimally invasive surgery are:

• Less postoperative pain
• Smaller scars
• Less blood loss
• The ability to mobilize early
• Fewer lung complications
• Shorter hospital stay
• Faster return to daily life

Our clinical observations and data from the literature show that oncologic clearance, that is complete removal of the cancerous tissue, is at least as successful with minimally invasive methods as with open surgery, while patient comfort is much higher.

When is the Ivor Lewis technique preferred in esophageal cancer surgery?

One of the technical terms you may hear in esophageal cancer surgery is “Ivor Lewis.” Do not let this intimidate you; it actually describes a strategy indicating from which route the surgery will be performed. This technique is generally preferred when the tumor is located in the lower part of the esophagus or at the junction with the stomach.

The Ivor Lewis operation consists of two stages. In the first stage, we enter through the abdominal region (usually laparoscopically, that is minimally invasively). The stomach is freed from the surrounding tissues and shaped into a tube. In the second stage, we enter through the chest cavity (from the right side), remove the diseased part of the esophagus, pull the prepared gastric tube into the chest, and join it to the remaining esophagus there.

The most important feature of this method is that no incision is made in the neck region. The anastomosis is performed inside the chest, in the space behind the heart. This technique is also frequently preferred by surgeons because it reduces the risk of damage to the nerves controlling the vocal cords.

In which cases is the McKeown technique used in esophageal cancer surgery?

If the tumor is located in the upper parts of the esophagus, that is closer to the neck or in the mid-esophagus, we change our strategy. In this case, the technique we call “McKeown” or “Three-incision” comes into play. As the name suggests, this operation involves three regions: the abdomen, chest, and neck.

In this technique, the aim is to remove almost the entire esophagus and also clear the lymph nodes in the neck region. Because tumors in the upper region have a higher likelihood of spreading to neck lymph nodes.

The stages of the McKeown technique are:

• Chest stage
• Abdominal stage
• Neck stage

First, the esophagus is mobilized through the chest cavity. Then, a gastric tube is prepared through the abdominal region. Finally, the esophagus is removed through an incision in the neck, and the gastric tube is pulled up to the neck and connected there. This method provides the surgeon with a very wide field for clearance. It allows us to obtain oncologically safer margins.

What is used instead of the esophagus during surgery?

This is the issue that our patients are most curious about and often find difficult to imagine: “If you remove my esophagus, how will I eat?” Our body offers us a wonderful spare part for this: your own stomach.

During the abdominal stage of the operation, we cut and shape the stomach using special stapling devices. By preserving a large part of the stomach, we form it into a narrow and long tube. This newly created “gastric tube” is very similar in shape to the esophagus. Preserving the blood vessels that supply the stomach is the most delicate point of this process, because the survival of this tube depends on those vessels.

This prepared gastric tube is then brought upward through the bed of the old esophagus and connected to the remaining healthy end of the esophagus above. In other words, food now passes from the mouth into the gastric tube and then into the intestines. If the patient’s stomach cannot be used due to a previous surgery or disease, segments of the colon or small intestine can also rarely be used instead of the esophagus.

What are the most common complications after esophageal cancer surgery?

To be honest, esophageal surgery is one of the biggest interventions performed on the human body, and like every major surgery, it has risks. Although we surgeons take every precaution, tissue healing and the body’s response vary from person to person. Knowing these risks is very important for early intervention.

The main complications we may encounter are:

• Anastomotic leakage
• Pneumonia
• Atelectasis
• Cardiac rhythm disturbances
• Hoarseness
• Wound infection
• Difficulty emptying the stomach

The condition we fear most on this list is “anastomotic leakage.” This means leakage from the suture line where the esophagus and gastric tube are stitched together. If the sutures do not heal fully, saliva or stomach contents may leak out.

There is an interesting detail here: In neck anastomoses (McKeown), the leakage rate is somewhat higher because the stomach is pulled all the way to the top and blood supply may become more difficult. However, a leak in the neck region generally does not create a life-threatening situation and often heals with simple dressings. In chest anastomoses (Ivor Lewis), leakage is less common, but if it occurs, it is much more dangerous because the leakage flows directly into the chest cavity near the heart. Therefore, we monitor our patients very closely in the postoperative period.

Why are the lungs so important during recovery?

After surgery, the issue that challenges our patients most is usually not the surgical area but the lungs. During the operation, in order to clear the lymph nodes, we sometimes have to deflate the lungs for a period. In addition, because of postoperative pain, the patient may avoid taking deep breaths. This can lead to collapse of the small air sacs in the lungs (atelectasis) and accumulation of mucus there. If this mucus cannot be expelled, pneumonia may develop.

To minimize this risk, we have a rule of “early mobilization.” We get our patients up and walking the day after surgery, sometimes even on the same evening. Walking and staying upright are the best medicines to help the lungs re-expand. In addition, using breathing exercise devices that we call “triflow,” which contain small balls, is an indispensable part of the recovery process.

We see the greatest benefit of minimally invasive methods here. Because the chest wall is not cut, the patient feels less pain, can cough more comfortably, and breathe more easily. This significantly reduces the risk of lung complications.

Do benign esophageal tumors require surgery?

Not only cancer but sometimes benign tumors can also develop in the esophagus. The most common of these are masses arising from the muscle layer, which we call “leiomyoma.” These are usually detected incidentally and have a very low risk of turning into cancer.

If the tumor is small and does not cause any complaints, simple follow-up is sufficient. However, if the tumor grows and causes difficulty swallowing or pain, surgical intervention becomes necessary. In benign tumors, we do not cut out the esophagus as in cancer surgery. Instead, with a method called “enucleation,” we carefully peel the tumor out without damaging the inner lining of the esophagus. Today this procedure is also mostly performed thoracoscopically, that is with a minimally invasive approach, without leaving large scars on the chest.

How should nutrition be after esophageal cancer surgery?

After a successful operation and recovery process, a new life routine awaits our patients. The stomach is no longer a “storage reservoir” as before but rather a passageway. In addition, because the natural valve mechanism preventing stomach acid from reaching the throat is removed, eating habits must change completely.

The basic nutritional rules that should be followed after surgery are:

• Eat small and frequent meals
• Chew each bite very thoroughly
• Do not drink water during meals
• Do not lie down immediately after eating
• Sleep in an upright position
• Avoid gas-producing foods
• Limit sugary foods

Particular attention should be paid to the condition called “Dumping Syndrome.” Since the gastric tube empties food rapidly into the intestine, eating very sugary or carbohydrate-rich foods may cause sudden weakness, palpitations, and sweating. Therefore, eating slowly and reducing sugar intake are very important. Over time, the body adapts to this new anatomy, and our patients once again enjoy sharing the table with their loved ones.

What is the success rate in esophageal cancer surgery?

Esophageal cancer surgery is one of the most challenging and discipline-demanding fields in medicine. However, the point we have reached today is encouraging. Thanks to advanced imaging methods, minimally invasive surgical techniques, intensive care facilities, and smart drugs, we are now able to fight this disease much more effectively.

Although the chance of success varies according to the stage of the disease and the patient’s general condition, complete cure is possible with the right surgery performed at the right time. The most critical point here is that these operations are carried out in experienced centers and by specialized teams.

Frequently Asked Questions