Surgery for cancer of the oesophagus

The oesophagus is a long tube that can be divided into three parts- the upper, middle and lower third. Surgery for cancer of the oesophagus depends on the location of the cancer and the type of cancer. There are two operations that are performed- either a 2- stage procedure also called Ivor-Lewis oesophagectomy or a 3- stage procedure.

The principle of the operation is to

Remove either the lower half of the oesophagus or most of the oesophagus
Pull up the stomach as a tube into the chest to join to the remaining oesophagus
Remove all the lymph glands around the oesophagus and stomach. This is because nearly all oesophageal cancers spread to the lymph glands. In addition to removing all the disease and thus reducing the likelihood of the cancer coming back, removal of the lymph glands also helps to determine prognosis more accurately and plan further treatment accordingly.

2 stage oesophagectomy

1st stage: In this stage the stomach is freed from its attachments, the abdominal lymph glands are dissected in order to be removed en-bloc (removed attached to the cancer specimen), the stomach is converted into a tube and a feeding tube is inserted into the bowel. This stage is done either through a traditional open technique or by key-hole surgery (laparoscopy). In the open technique a cut is made across the abdomen. In laparoscopic surgery, the steps described above are performed through 5-6 small (1cm or less) cuts through which special instruments are used.

2nd stage: Following this the patient is turned over to the side and the lower oesophagus along with the attached lymph glands are removed, the stomach in pulled up into the chest and a join is made between the stomach tube and the remaining oesophagus. This stage is usually performed by an open technique where a cut is made across the chest and the ribs are retracted to gain access into the chest.

3 stage oesophagectomy

1st stage: In this procedure the chest component of the operation is performed first. The whole oesophagus and the attached lymph glands are dissected to be removed through the abdomen later. This can be done by the open technique or through the key-hole technique. In the open technique the patient is turned over to the side and a cut is made across the chest and the ribs are retracted to gain access into the chest. In the key hole technique the patient may be turned over to the side or may be turned over and lying prone (chest and abdomen down).

2nd stage: In this stage the patient is supine (lying on the back). The stomach is freed from its attachment, the abdominal lymph glands are dissected in order to be removed en-bloc (removed attached to the cancer specimen), the stomach is converted into a tube and a feeding tube is inserted into the bowel. This stage is done either through a traditional open technique or by key-hole surgery (laparoscopy). In the open technique a cut is made either across the abdomen. In laparoscopic surgery, the steps described above performed through 5-6 small (1cm or less) cuts through which special instruments are used).

3rd stage: With the patient supine, a cut is made on the left side of the neck and the oesophagus in the neck is dissected. The oesophagus is cut at this level and the whole oesophagus, dissected free in the first stage, is pulled out through the abdomen. The stomach tube is then pulled through the chest into the neck and a join is made between the stomach tube and the remaining oesophagus in the neck.

Pre-operative preparation and care

Depending on the stage of the cancer, most patients would have received chemotherapy and it is advisable to wait for at least 4 weeks after completion of the chemotherapy or 6-8 weeks after completion of chemoradtiotherapy, before undertaking surgery to allow the body to recover.
Pre-operative assessment involves blood tests, lung function tests to assess the lungs and an echocardiography to assess the heart.
Patients are admitted the night before surgery and pre-medication is administered to calm the patient.
Most regular medications can be taken on the morning of surgery as per the advice of the surgeon and the anaethetist.
Patients who are diabetics will be started on a insulin drip.
You should not eat for 6 hours prior to the surgery but you can have water and other clear liquids for upto 2 hours before surgery.
If you are a smoker, you should stop smoking at least 4 weeks before surgery.
You will be taught breathing exercises that you will be encouraged to perform from the day after the surgery. You must practice these even before the surgery.

Post-operative care

You will be admitted to the Intensive Care Unit for at least 5 days after the operation.

At the end of the procedure, you will wake up with a tube in your nose, one tube (drain in your abdomen), one or two drains in the right side of your chest, a urinary catheter, a line in your neck (central line) and another line in your forearm (arterial line) and a feeding tube inserted into your abdomen. If there are no complications, all these tubes and lines will be taken out between the third to the fifth days. By the sixth post-operative day all tubes, drains and lines should be out.

Pain control

There will be a epidural catheter inserted into your back. This numbs all the pain nerves supplying the abdomen and thus controls post-operative pain. While there maybe a bit of discomfort when you move or cough, it is essential that you let the nurse looking after you know if you are in any pain.

After 5 days, the epidural catheter will be taken out and you will receive pain medication as tablets or as a drip depending on whether you are having orals or not.

Fluids and diet

You will be nil by mouth (NBM) for the first five days after surgery. In this period you will receive nutrition through the feeding tube in your abdomen. On the fifth day you will undergo a special x-ray where you will requested to swallow a dye to ensure that is no leak in the new join between the food pipe and the stomach. When it is confirmed that there is no leak, you will be on fluids (including nutritional supplements) and should be able to have pureed food by the fifth day.

Sitting and walking after surgery

You must try your best to sit out in a chair for at least 2 hours in the morning and two hours in the evening. Sitting up helps to keeps the lungs open and prevents lung collapse and pneumonia.

You must also take a few steps around the ward from the first day itself and gradually increase the distance you walk with every day. This helps in keeping the lungs open and also keeps the blood in your veins flowing and prevents clots forming in your lungs. In order to prevent clots you will also be encouraged to wear special stockings and will be given one dose of blood thinning medication (heparin) everyday.

Discharge

If all goes well and there are no complications, you will be ready for discharge by the tenth day after surgery. This will be when you all the observations and blood tests are within the normal range, you are in minimum pain, independently walking and getting out of bed and eating adequate amounts of food.

At Home

Oesophagectomy is a major operation. It takes nearly 2 months to completely recover from the surgery. However, you should be able to undertake light activities once you are home. You should be able to go out of your house for a short walk everyday. You should be as active as possible to prevent clots forming in your legs.
As the stomach is now a narrow tube, you will feel full quite rapidly. Thus you must have small and frequent meals. You will be given dietary advice after surgery.
You will lose around 5 kgs (nearly a stone) after surgery. This is very common and is due to a combination of factors.
You may also experience some nausea and loss in appetite. You will be given medication to control these symptoms.
You maybe discharged home on home feeds throught he feeding tube in your tummy. You will training for this while you are in hospital and the feeds will be delivered to your home.

Side effects/complications of oesophagectomy

Being a very major operation, there is a risk of complications. How the risk of any major life threatening complication is less than 10%.

Pneumonia: This is common after surgery and can occur in 30-40% of patients. This is due to a combination of factors. The risks can be reduced by pre- operative exercises including breathing exercises and through effective post- operative pain control, walking and breathings exercises.

Leakage: The join between the remaining oesophagus and the stomach tube may leak. Most of the leaks will heal by themselves but take around 2-6 weeks to do so. Rarely a reoperation is required to close the leak. A leak may present as infection inside the chest or neck or as a collection of pus. These can be managed with antibiotics and insertion of drains by the radiologists in the CT scan department.

Chyle leak: Chyle is a fluid rich in proteins which is carried into the blood from the intestine through a small tube called the thoracic duct. While this is carefully seen and tied during surgery, there is small risk that this fluid can leak out of the thoracic duct after surgery. Chyle leaks should settle without any problems but rarely repeat surgery maybe needed to find the duct and secure the tie.

Heart problems such as a heart attack occur rarely as a result of the effect of the major surgery on the heart.

Clots in the legs/lungs (Thrombosis): Major surgery is a risk factor for getting clots but every attempt is made to reduce the risk through use of stockings while patients are in hospital and through the administration of blood thinning medications such as heparin.

Bleeding: can usually managed by blood transfusions and rarely it maybe necessary to reoperate to stop the bleeding.

Nutritional problems: You will be closely followed up by a dieticien as a healthy diet is essential to prevent nutritional problems after surgery.

Diarrhoea: this is quite common and due to the cutting of the vagus nerves which occurs during the surgery. These nerves supply the bowel and play a role in coordinating bowel movement. However, the nerves have to be cut to perform the operation. The diarrhoea can usually be controlled with medications.

Feeling full: The stomach is not a big bag anymore. It is a narrow tube and will not be able to accommodate large amounts of food. This results in a feeling of fullness soon after meals. It is thus essential that you eat small amounts of food frequently.

Dumping syndrome: This is an uncommon side effect which is due to the sudden rush of sugars (carbohydrates) in the food into the bowel. This produces a surge in the blood insulin which then reduces the sugars in your blood. You can experience light headedness, sweating, nausea. This is controlled by reducing the sugars in your food, eating slowly, chewing your food really well and drinking water after meals and not with meals.

Vocal cord palsy: This occurs in patients who have had a 3-stage oesophagectomy. Operating in the neck could damage the nerves supplying the vocal cords. While this is rarely permanent, the effect can last for a few weeks. Patients will experience a hoarseness of voice and weakness of the vocal cords can also predispose patients to pneumonia.

Follow-up after surgery

You will be seen by the surgeon 2 weeks and 6 weeks after surgery. Following that you will be seen every 3 months for the first 2 years and then every 6 months from years 3-5. After that you will be seen every year.

Further treatment after surgery

Depending on the laboratory results of the cancer removed at surgery you may or may not need further chemotherapy or radiotherapy. The oncologist will discuss this with you.

Surgery for cancer of the stomach

The stomach is divided into areas called the cardia, fundus, body, antrum and pylorus. The shorter edge of the stomach is called the lesser curve and the longer edge is called the greater curve.

Depending on the location of the cancer, surgery involves removal of the whole stomach or part of the stomach.

A subtotal gastrectomy involves removal of around 75% of the stomach when the tumour is situated in antrum or the pylorus and for some cancers in the body.

A total gastrectomy involves removal of the whole stomach when the tumour is situated in the cardia, fundus or body.

In some rare cases tumours in the upper stomach can be operated by removing the top half of the stomach but this is rarely done as this does not give any advantage over complete removal.

All cancer operations must also involve removal of all the lymph glands around the stomach. This is because nearly all stomach cancers spread to the lymph glands. In addition to removing all the disease and thus reducing the likelihood of the cancer coming back, removal of the lymph glands also helps to determine prognosis more accurately and plan further treatment accordingly.

Gastrectomy is a major operation. It takes between 3-5 hours to perform. Results from a gastrectomy depend on the skill and experience of the surgeon. It is particularly important to ensure that all possible lymph glands are removed during surgery.

Pre-operative preparation and care

Depending on the stage of the cancer, most patients would have received chemotherapy and it is advisable to wait for at least 4 weeks after completion of the chemotherapy, before undertaking surgery to allow the body to recover.
Pre-operative assessment involves blood tests, lung function tests to assess the lungs and an echocardiography to assess the heart.
Patients are admitted the night before surgery and pre-medication is administered to calm the patient.
Most regular medications can be taken on the morning of surgery as per the advice of the surgeon and the anaethetist.
Patients who are diabetics will be started on an insulin drip.
You should not eat for 6 hours prior to the surgery but you can have water and other clear liquids for upto 2 hours before surgery.
If you are a smoker, you should stop smoking at least 4 weeks before surgery.
You will be taught breathing exercises that you will be encouraged to perform from the day after the surgery. You must practice these even before the surgery.

Post-operative care

You will be admitted to the Intensive Care Unit (ICU) or High Dependancy Unit (HDU) for at least 3 days after the operation.

At the end of the procedure, you will wake up with a tube in your nose, two tubes (drains in your abdomen), a urinary catheter, a line in your neck (central line) and another line in your forearm (arterial line). The central and arterial lines are for your safety to ensure that you are closely observed after the procedure. If there are no complications, all these tubes and lines will start coming out from the third day to the fifth day. By the sixth post-operative day all tubes, drains and lines should be out.

Pain control

After 5 days, the epidural catheter will be taken out and you will receive oral pain medication.

Fluids and diet

Subtotal gastrectomy: you will start on fluids from the first day itself and should be on a pureed diet by the third day. Once you are on fluids you will also be asked to drink nutritional supplements. You will be on soft diet on days 4 and 5 and a normal healthy diet after that.

Total gastrectomy. You will be requested to have only sips of water for the first three days after surgery. On the third day you will undergo a special x-ray where you will requested to swallow a dye to ensure that is no leak at the new join between the food pipe and the bowel. When it is confirmed that there is no leak, you will be on fluids (including nutritional supplements) and should be able to have pureed food by the fifth day. On some occasions, patients may also be fed with a small feeding tube which will be inserted into the bowel during the surgery. This is called a feeding jejunostomy.

Sitting and walking after surgery

You must try your best to sit out in a chair for at least 2 hours in the morning and two hours in the evening. Sitting up helps to keeps the lungs open and prevents lung collapse and pneumonia.

Discharge

If all goes well and there are no complications, you will be ready for discharge by the seventh after surgery. This will be when you all the observations and blood tests are within the normal range, you are in minimum pain, independently walking and getting out of bed and eating adequate amounts of food.

At Home

Gastrectomy is a major operation. It takes nearly 2 months to completely recover from the surgery. However, you should be able to undertake light activities once you are home. You should be able to go out of your house for a short walk everyday. You should be as active as possible to prevent clots forming in your legs.
As there is no stomach, you will feel full quite rapidly. Thus you must have small and frequent meals. You will be given dietary advice after surgery.
You will lose around 5 kgs (nearly a stone) after surgery. This is very common and is due to a combination of factors.
You may also experience some nausea and loss in appetite. You will be given medication to control these symptoms.

Side effects of gastrectomy

Being a very major operation, there is a risk of complications. How the risk of any major life threatening complication is less than 10%.

There are some complications which occur as side effects of any major procedure under general anaesthesia such as thrombosis of the legs and the lungs, pneumonia, heart attacks etc. Fortunately with safe anaesthesia these are quite rare nowadays. They occur more commonly in people who already have existing heart or lung diseases.

Complications specific to gastrectomy

Leak: The join between the remaining stomach (sub total) or the food pipe (total) and the small bowel may leak. Most of the leaks will heal by themselves but take around 2-6 weeks to do so. Rarely a reoperation is required to close the leakage. A leak may present as infection inside the abdomen (peritonitis) or as a collection of pus. These can be managed with antibiotics and insertion of drains by the radiologists in the CT scan department.
Bleeding: can usually managed by blood transfusions but rarely it maybe necessary to reoperate to stop the bleeding.
Nutritional problems: You will be closely followed up by a dieticien as a healthy die is essential to prevent nutritional problems. It will not be possible to absorb Vitamin B12 after the removal of the whole stomach and you will need Vit B12 injections every 3 months after a total gastrectomy and rarely even after a sub-total gastrectomy.
Diarrhoea: this is quite common and due to the cutting of the vagus nerves which occurs during the surgery. This can usually be controlled with medications.
Dumping syndrome: This is an uncommon side effect which is due to the sudden rush of sugars (carbohydatres) in the food into the bowel. This produces a surge in the blood insulin which then reduces the sugars in your blood. You can experience light headedness, sweating and nausea. This is controlled by reducing the sugars in your food, eating slowly, chewing your food really well and drinking water after meals and not with meals.

Follow-up after surgery

Further treatment after surgery

Depending on the laboratory results of the cancer removed at surgery you may or may not need further chemotherapy or radiotherapy. The oncologist will discuss this with you.