Esophageal Surgery | Specialists and Information

There are many reasons for performing surgery on the esophagus or on adjacent structures such as the stomach or the diaphragm. These include:

• Esophageal malformations, such as esophageal atresia, in which the esophagus either has no connection to the stomach or is so severely narrowed that food cannot pass through, or congenital or acquired esophagotracheal fistula, in which there is a connection between the esophagus and the trachea
• Injuries, for example, caused by swallowed foreign bodies or a spontaneous esophageal rupture due to forced vomiting (emetogenic esophageal rupture, Boerhaave syndrome)
• Hiatal hernia: In a hiatal hernia, parts of the stomach protrude through the opening in the diaphragm through which the esophagus passes
• Achalasia: Inability of the lower esophageal sphincter to open sufficiently to allow food to pass into the stomach
• Diverticula (outpouchings) of the esophagus
• Esophageal cancer (esophageal carcinoma), such as squamous cell carcinoma (cancer originating in the esophageal mucosa) or adenocarcinoma of the esophagogastric junction (Barrett’s carcinoma, cancer of the region where the esophagus meets the stomach, originating from glandular cells)
• Esophageal leiomyomas: benign tumors of the esophageal musculature that, in rare cases, can develop into malignant leiomyosarcomas
• Reflux disease: Due to a malfunction of the sphincter at the junction of the esophagus and stomach, the reflux of acidic stomach contents into the esophagus can lead to chronic heartburn, inflammation (Barrett’s esophagus), ulcers, and strictures, and—in the long term—Barrett’s carcinoma

In the past, esophageal surgery was performed using open surgical techniques, which required opening the abdominal cavity (laparotomy) and the chest cavity (thoracotomy). The open surgical procedure can be associated with significant surgical trauma and, consequently, pulmonary (lung) complications in particular, as well as an increased risk of death.

These risks of complications can be minimized through minimally invasive surgery. Therefore, partially (hybrid technique) or completely minimally invasive procedures are now considered the gold standard in esophageal surgery.

Procedures used in esophageal surgery include, for example:

• Laparoscopic (i.e., via laparoscopy) repair of a hiatal hernia
• Open or minimally invasive procedures for diaphragmatic hernias, often using a synthetic mesh
• Endoscopic dilation (known as pneumatic balloon dilation) of the lower esophageal sphincter or laparoscopic division of the muscles of the lower esophagus and the entrance to the stomach (cardia; known as Heller myotomy) for achalasia
• Endoscopic or minimally invasive, rarely open, treatment of diverticula
• Excision (usually minimally invasive) of leiomyomas
• Superficial ablation of early-stage esophageal cancer (so-called early-stage carcinomas) during esophagoscopy
• Esophagectomy (removal of the esophagus) for advanced esophageal cancer
• Antireflux surgery for gastroesophageal reflux disease: Destruction of Barrett’s epithelium (abnormally altered esophageal mucosa) using heat during an esophagoscopy and reinforcement of the esophageal opening with stomach tissue during a laparoscopy (so-called laparoscopic fundoplication)

Esophagectomy and antireflux surgery are described in more detail below.

Esophagectomy (resection of the esophagus), i.e., the removal of the esophagus, is typically performed to treat esophageal cancer.

Although the first esophagus was removed in a patient with esophageal cancer as early as 1913, it was not until the 1980s that the mortality rate was reduced from an initial 90 percent to 20 percent. Today, this risk is less than four to five percent—but only if the surgery is performed by a proven expert at a facility that performs a high number of esophageal resections each year.

There are essentially two procedures for removing the esophagus:

• transhiatal esophagectomy, which involves removal through the opening in the diaphragm (esophageal hiatus) through which the esophagus enters the abdominal cavity; this requires an incision in the abdomen and an incision on the left side of the neck.
• transthoracic esophagectomy, in which the abdominal and thoracic cavities are opened.

Both procedures can be performed as open surgery or completely minimally invasively; a combination of open and minimally invasive techniques is possible and is called the hybrid technique.

Transhiatal esophagectomy is usually performed as an open surgical procedure and is primarily used for patients with impaired lung function. It is a treatment option particularly for tumors located in the lower third of the esophagus. However, due to the slightly better survival rate, transthoracic esophagectomy is the preferred procedure at many centers, particularly when performed as a minimally invasive procedure (thoracoscopic-laparoscopic esophageal resection), which has a lower complication rate compared to the open procedure. In difficult cases, the hybrid technique is often used.

After removal of the esophagus, the passage of food is maintained by reshaping a portion of the stomach into a tube and connecting it to the remaining esophagus. If the stomach also had to be removed, a portion of the large intestine or, less commonly, the small intestine can serve as a replacement for the removed esophagus.

The thoracoscopic-laparoscopic procedure—that is, a minimally invasive operation involving both the abdominal and thoracic cavities—begins with the patient lying on their back. Using special endoscopic instruments, the lower esophagus and surrounding lymph nodes are dissected through five small skin incisions in the abdomen, and the stomach is prepared to restore the passage of food.

Subsequently, with the patient in a lateral position and again through five small skin incisions, endoscopic instruments are inserted into the chest cavity, and the esophagus is dissected from the surrounding tissue up to just below where it enters the neck (Fig. 2).

If the tumor is located in the cervical portion of the esophagus, the neck must also be exposed. In most cases, however, the cervical portion of the esophagus does not need to be removed. Finally, the elevated gastric tube is connected to the remaining esophagus (Fig. 3), and the dissected esophagus, along with the lymph nodes, is removed from the body.

Fig. 2 Extent of resection for cancer of the lower esophagus

Fig. 3 Reconstruction following radical esophagectomy using a gastric tube

The cause of reflux is usually a hiatal hernia in which the upper part of the stomach slides up into the chest cavity, disrupting the valve mechanism. Consequently, treatment consists of surgical repair of the hiatal defect, which can now routinely be performed using minimally invasive techniques. The following three laparoscopic (via abdominal endoscopy) methods have become established as standard procedures, with the first being the most common and the last by far the least common:

• laparoscopic Nissen fundoplication
• laparoscopic fundoplication according to Toupet
• laparoscopic fundoplication according to Dor

In these laparoscopic procedures, the first step involves narrowing the hiatal opening (hiatoplasty), and the second step involves wrapping the gastric dome around the lowermost part of the esophagus in the form of a cuff (fundoplication). This is intended to keep the esophagus stretched so that the valve mechanism functions properly again (Fig. 4). The three methods mentioned above differ in whether the cuff is placed completely (360°, according to Nissen), partially (230–270°, according to Toupet), or only in the anterior region (according to Dor).

Fig. 4: Laparoscopic narrowing of the hiatal opening (hiatoplasty) and placement of a gastric dome cuff around the esophagus (fundoplication)

Hiatoplasty is performed using sutures and, occasionally in cases of larger hiatal hernias, with additional stabilization using an artificial mesh.

The surgery is successful and provides long-term relief. It should be offered to all patients

• who do not achieve symptom relief with medication or who must take medication for the rest of their lives,
• who suffer from severe reflux of stomach contents, or
• whose acid reflux leads to irritation of the larynx and bronchi.

As alternative treatment options, three new procedures are currently showing promise and are being investigated in clinical trials:

• Laparoscopic placement of a magnetic ring around the lower esophageal sphincter
• Transoral incisionless fundoplication, i.e., performed through the mouth without skin incisions
• Implantation of an electrical stimulation device to improve the function of the lower esophageal sphincter

Esophageal surgery places a significant burden on patients; however, the complication rate has been steadily reduced over the past few decades thanks to minimally invasive procedures.

After esophagectomy, patients must relearn how to eat. They will not feel hungry for some time, and food must be divided into several small, individual portions. In principle, there is no standard diet; rather, each patient explores what works best for them. A rehabilitation program lasting several weeks is recommended for this purpose. However, quality of life is determined primarily not by the consequences of the surgery, but by the possibility of cancer recurrence.