Surgical Procedures:
Surgery for Oesophageal Cancer
Surgery offers the only chance of cure for oesophageal cancer. Early diagnosis and surgical intervention is crucial. Cancers of the oesophagus can occur anywhere in the oesophagus, but most commonly occur at the junction of the oesophagus and stomach.
What is involved in surgery for Oesophageal Cancer?
Surgery for oesophageal cancer is major surgery requiring hospitalisation for 10 to 14 days. It is routine for patients to be admitted to the Intensive Care Unit postoperatively due to the scale of the procedure. Thorough preoperative anaesthetic consultation is mandatory to ensure optimal physical condition prior to surgery.
The operation itself involves a full general anaesthetic. Once anaesthetised, several procedures are carried out to ensure the safety of the patient prior to surgery commencing. These usually include
- Insertion of central line - a special canula into the larger neck veins to allow the anaesthetist to administer drugs.
- Insertion of urinary catheter - allows careful monitoring of kidney function during and after the operation.
- Nasogastric tube placement - a fine tube passed through the nose and into the stomach to keep the stomach deflated.
- Arterial line - a type of canula that is placed into the artery in the wrist. This allows constant, accurate blood pressure measurements during and after the operation.
Most tumours of the oesophagus are located at the lower end of the oesophagus. To gain adequate exposure and clearance of the tumour, two separate incisions are required. The first is in the upper abdomen to gain access to the stomach and lower oesophagus. The second incision is in the right side of the chest wall to enter the chest cavity to gain access to the upper part of the oesophagus.
The basic principles of the operation are to remove the tumour with large surgical margins, as well as clearing the draining lymph nodes that the cancer can spread to. Extensive lymph node dissection and removal has shown increased survival benefits and is routinely practised by Dr Fenton Lee.
Reconstruction of the upper gastrointestinal tract by anastomosing the upper part of the oesophagus to the stomach in the chest cavity completes the procedure.
Abdominal Stage
The first part of the operation involves an upper, midline incision approximately 25cm in length. Despite previous staging procedures, the abdominal cavity is thoroughly examined to exclude metastatic disease which staging tests sometimes miss. This occurs rarely with thorough preoperative staging techniques used by Dr Fenton-Lee.
Following this, the lower oesophagus, the entire stomach and the duodenum is mobilised or freed from its attachments in the abdomen. This allows the stomach to be pulled up into the chest cavity for re-anastomosis once the tumour has been removed.
Once this has been achieved, the abdominal incision is closed and the second part (thoracic stage) of the operation may commence.
Thoracic Stage
The thoracic stage involves a transverse incision parallel to the ribs in the upper part of the right chest wall. This allows entry into the right side of the chest or thoracic cavity. The right lung is deflated by the anaesthetist to prevent damage to the lung during the operation and to allow proper access to the oesophagus which lies deep down against the vertebral bodies.
The oesophagus is then mobilised or freed from its attachments. Once the oesophagus is completely mobilised, the previously mobilised stomach can be pulled up into the thoracic cavity. The cancerous part of the oesophagus is then removed.
Due to the rich lymph drainage of the oesophagus, wide margins, as well as most draining lymph nodes are removed with the tumour.
The final step of the operation is re-anastomosing the stomach to the oesophagus. This is done in the upper part of the chest cavity usually with special stapling instruments that join the two ends together. Alternatively, they can be hand stitched together with sutures.
Once re-anastomosis is complete, the right lung is re-inflated. To ensure the lung remains inflated, two special drains known as intercostal catheters are placed in the chest cavity and attached to external drainage bottles. The incision is then closed and dressings applied.
The procedure usually takes 3-4 hours to complete. The specimens are sent to the pathology laboratory for evaluation. This normally taking 5 to 7 days to complete.
What will i be like after the operation?
As with any major surgical procedures, post operative care and the prevention of complications is crucial to the success of the procedure.
All patients following surgery for oesophageal cancer are admitted to the intensive care unit. The main reason for this is to ensure breathing difficulties do not arise as the result of the right lung being collapsed for much of the operation. It also allows constant blood pressure and pulse monitoring immediately following the operation. The nasogastric tube, urinary catheter, arterial line and central line inserted at the beginning of the procedure remain. In addition, the two chest drains inserted at the completion of the operation are present. Most patients will also have special stockings and twice daily injections of an anti clotting medication to help prevent deep vein thrombosis.
The first three or four days are often the most crucial and difficult. Adequate pain control, early mobilisation and regular physiotherapy treatment to prevent chest infection is mandatory. Discharge from intensive care to the ward is usually achieved after 2-3 days.
No oral intake is allowed for the first 4-5 days to allow the anastomosis to begin healing. A specialised x-ray test is usually performed at day 5 to ensure there is no leak from the anastomosis. Once this is done, a diet can slowly be introduced over the next few days.
Nasogastric tube, urinary catheter, central lines and chest drains are gradually removed once mobilisation improves and diet is tolerated. Patients are able to return home once they are mobilising independently, pain control is achieved with oral medications and they are tolerating a normal diet. This is generally achieved between 10 to 14 days following the operation.
Prior to discharge, pathology results are discussed. If other forms of treatment such as chemotherapy are considered, this is arranged with specialist oncologists at St Vincent's Hospital during admission.
Due to the extent of the operation, rehabilitation and recovery continues at home and as an outpatient. Full recovery often takes six to twelve months to complete.
During this time, regular follow up with Dr Fenton-Lee in his rooms occurs.
What complications can occur?
Despite the complexity and long recovery period of this procedure, complications are uncommon, but can include
- Bleeding/Infection
Significant bleeding during or following the operation is rare. Post operative infection within the abdomen, chest cavity or wound infections are also rare complications. These complications are reduced by the administration antibiotics at the time of operation.
- Chest problems
Chest infections and prolonged periods to recover full respiratory function were common in the past. With the introduction of improved pain control methods and regular physiotherapy, lung complications have been vastly reduced.
- Anastomotic leaks
This is also now rare. Specialised x-ray tests are performed usually 5 days post operatively to ensure this has not occurred. Minor leaks can be treated without re-operation, but most leaks require repair with surgery.
- Anastomotic stenosis
Narrowing or stenosis at the site of anastomosis is also uncommon. When it does occur, a simple procedure called dilatation usually sufficient to repair the stenosis.
- Chyle leak
Due to extensive lymph node dissection, rarely, lymph fluid known as chyle can leak from where they where resected. This usually stops without further treatment, but occasionally can continue for prolonged periods. In extreme cases, re-operation is required to repair the leak.
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