Oesophagectomy refers to the surgical removal of the oesophagus, and diseased lymph nodes. Lymph nodes are the primary site for the spread of cancerous disease, and are often used to stage the severity of cancer.
In previous years, it was the first-line of treatment for patients with high-grade dysplasia and oesophageal cancer (e.g: intramucosal carcinoma). However, due to the high mortality of 1.2% associated with the procedure, compared with a 0.04% mortality associated with minimally/non-invasive endoscopic procedures it has fallen out of favour as a first-line therapy for the vast majority of patients. Additionally, oesophagectomy is associated with a range of adverse side-effects including respiratory complications, infections, and nerve damage (1).
Oesophagectomy (with resection of lymph nodes) is primarily reserved, nowadays, for patients with cancer that extends beyond the superficial layer of oesophagus, due to the increased risk of metastatic disease (the risk of cancer spreading throughout the body) (2,3). It may also be reserved for patients who were not successfully treated using endoscopic therapies.
Unfortunately, oesophagectomy has a 2-year cure rate of between 78-85%. So post-operative endoscopic surveillance is necessary
There are three main approaches to oesophagectomy:
Minimally invasive oesophagectomy involves video-guided laparoscopy(keyhole surgery). The advantages of this procedure are fewer lung-related complications, shorter recovery time and quicker discharges. However, the mortality and morbidity rates are not lower than more invasive procedures.
The other two surgeries are performed by making two cuts to allow access into the patient’s chest. In the trans-hiatal approach, the upper cut is in the neck region and the lower cut is in the abdomen. In the trans-thoracic approach, the upper cut is made in the chest and the lower cut in the abdomen. The oesophagus is then mobilised, the diseased section removed and the stomach is re-joined to the upper part of the oesophagus. Lymph nodes are also removed(4).
The incidence of lung-related complications is lower for the trans-hiatal approach although the survival rate was slightly higher for the trans-thoracic approach at 5-years (39% v.s 27%) (5). Additionally, resection of lymph nodes for staging is not possible via a trans-hiatal approach (6).
A surgical option for patients with Barrett’s oesophagus and reflux symptoms that do not respond to medical therapy is anti-reflux surgery (fundoplications). In this treatment, the stomach is wrapped around the lower-end of the oesophagus. This creates a pressure gradient at the end of the oesophagus and prevents reflux of acid from the stomach (7). There is no evidence that anti-reflux surgery is superior to treatment with PPIs in preventing progression of Barrett’s disease to dysplasia or adenocarcinoma (8).