Esophagogastrectomy is a surgical procedure in which a section of diseased esophagus is removed, along with part of the stomach and neighboring lymph nodes. The remaining piece of the esophagus is then reattached to the remaining stomach.
Esophagogastrectomy is performed to treat cancer of the esophagus. There are two types of esophageal cancer: squamous cell and adenocarcinoma. Squamous cell cancer of the esophagus used to be the most common type, but now is only responsible for fewer than 50% of cases of esophageal cancer. Squamous cell cancer occurs when the cells of the esophageal lining convert into malignant cells. This type of esophageal cancer is more common in white patients. Adenocarcinoma of the esophagus often follows a condition called Barret’s esophagus, in which the lower cells of the esophagus convert into cells resembling the glandular cells of the stomach. Over time, these abnormal Barret’s cells have the potential of converting into truly malignant cells. Adenocarcinoma of the esophagus is the more common type of esophageal cancer in African-American patients.
Men are three to four times more likely to develop esophageal cancer than are women, and African-Americans are about 50% more likely to develop the condition. According to the American Cancer Society, about 16,470 new cases of esophageal cancer will be diagnosed in the United States in 2008, and the disease will be responsible for about 14,280 deaths. The disease is much more common in other countries, such as Iran, northern China, India, and southern Africa, where rates are between ten and 100 times as high as they are in the United States. Still, esophageal cancer rates among white men in Western countries are increasing steadily, at a rate of about 2% per year; the rate has held steady among white women. Among patients diagnosed at all stages of esophageal cancer, five-year survival rates are about 18% in white patients and 11% in African-American patients.
Patients who are taking blood thinners, aspirin, or nonsteroidal anti-inflammatory medications may need to discontinue their use in advance of the test, to avoid increasing the risk of bleeding.
Patients undergoing esophagogastrectomy require general anesthesia. This will be administered in the form of intravenous medications as well as anesthetic gasses that are inhaled. The patient will be intubated for the duration of the surgery, and a ventilator will breathe for them.
Esophagogastrectomy can be achived through a traditional upper abdominal incision, or through multiple very small laparoscopic incision. Traditional open abdominal esophagogastrectomy exposes the entire upper abdomen in order to allow careful visual inspection of all the structures and lymph nodes surrounding the stomach an esophagus. Laparoscopic esophagogastrectomy involves the introduction of a scope through one of the keyhole incisions, and the use of other tiny incisions for introducing the miniature
Adenocarcinoma— A cancer originating in glandular cells.
Barrett’s esophagus— A condition in which the esophageal tissue closest to the stomach contains highly abnormal cells that have a great likelihood of converting to frank cancer.
Squamous cells— A type of flat cell that usually is involved in the lining of organs.
Stricture— A narrowing, often due to scar tissue formation.
surgical instruments necessary for the operation. The exact technique utilized in the surgery will depend on where in the esophagus the cancerous segment is located, and how much of the stomach is involved. Surgical preference is to be able to preserve part of the esophagus, in order to allow it to be reconnected to the remaining stomach. In some cases, however, so much esophagus must be removed that there is not enough left to reattach to the stomach. When this occurs, a piece of intestine can be removed and used to connect the throat to the stomach. Requiring this step considerably increases the complexity and risks of the operation.
Patients will need to stop eating and drinking for about 12-16 hours prior to their operation. The evening before the operation, a series of enemas and/or laxatives are used to empty the GI tract of feces. An intravenous line will be placed in order to provide the patient with fluids, general anesthesia agents, sedatives, and pain medicines during the operation. A urinary catheter will be placed in the patient’s bladder. The patient will be attached to a variety of monitors to keep track of blood pressure, heart rate, and blood oxygen level throughout the procedure.
Esophagogastrectomy is major surgery, and often requires that the patient remain hospitalized for recuperation for as much as two weeks after the operation. Over this time, the patient’s diet will slowly be reinstated, progressing gradually from liquids to soft foods to solids. Because esophageal cancer often causes symptoms of dysphagia (difficulty swallowing), a therapist specializing in re-teaching swallowing may be needed to help design a rehabilitative program.
Esophagogastrectomy carries a number of significant risks, including the general risks accompanying major surgery, such as blood clots, bleeding, heart attack, and infection. Specific complications that can occur with esophagogastrectomy include:
- Leakage of the new esophageal-stomach connection
- Slow stomach emptying due to surgical effects on the nerves controlling this function, sometimes resulting in chronic nausea and vomiting
- Severe heartburn if the lower part of the esophagus and upper part of the stomach are weakened by the surgery, allowing stomach contents to reflux back up into the esophagus
- Strictures or narrowing of the esophagus due to scarring from the surgery
The risk of fatal complications from esophagogastrectomy may range from about three to about seventeen percent. In general, studies have shown that hospital and surgeon experience with esophagogastrectomy reduces the risk of morbidity and mortality for patients.
Normal results occur when the cancerous tissue is completely removed, and a patent, functional connection is created between the remaining esophageal and stomach tissue.
Abnormal results range from remaining malignant tissue, to those complications detailed above, such as a leaky esophageal-stomach connection, chronic nausea secondary to nerve damage and slow stomach emptying, dysphagia due to strictures, etc.
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Goldman, L., D. Ausiello, eds. Cecil Textbook of Internal Medicine, 23rd ed. Philadelphia: Saunders, 2008.
Khatri, VP and JA Asensio. Operative Surgery Manual, 1st ed. Philadelphia: Saunders, 2003.
Rosalyn Carson-DeWitt, MD