While the oesophagus is a fairly simple organ from a functional point of view, it is a complex challenge from a surgical perspective. It is difficult to reach behind the lungs and there is a risk of injuring the lungs, nearby large blood vessels, the spleen or the diaphragm during the procedure.
Oesophageal surgery therefore belongs to the field of highly specialized medicine and should be performed in specialized centers due to the risk of complications - the success of the treatment depends largely on the surgeon's experience.
The oesophagus is a muscular tube about 25 centimetres long that connects the mouth to the stomach and is used to transport food. This transportation is an active process and takes place through reflexive wave-like muscle contractions.
At the same time, the lower sphincter prevents the backflow (reflux) of gastric juice and food pulp from the stomach into the oesophagus. There is also a sphincter muscle at the upper end towards the mouth.
The oesophagus is divided into three sections:
- Neck section (cervical area)
- Chest section (thoracic area)
- Esophagus-gastric junction (esophagogastric junction)
Fig.1 Schematic anatomy of the esophagus. It passes through the neck, chest and, after passing through a diaphragmatic hiatus, the abdominal cavity.
There are many reasons for surgery on the oesophagus or adjacent structures such as the stomach or 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 trachea
- Injuries caused, for example, 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 pass through the opening in the diaphragm through which the oesophagus passes
- Achalasia: Inability of the lower sphincter to open sufficiently for food to pass through into the stomach
- Diverticula (protrusions) of the oesophagus
- Esophageal cancer (esophageal carcinoma) such as squamous cell carcinoma (cancer originating from the mucous membrane of the esophagus) or adenocarcinoma of the esophagogastric junction (Barrett's carcinoma, cancer of the transition region of the esophagus and stomach that originates from glandular cells)
- Leiomyomas of the esophagus: benign tumors of the esophageal muscles that can develop into malignant leiomyosarcomas in rare cases
- Reflux disease: due to a malfunction of the closing mechanism at the entrance from the oesophagus into the stomach, a reflux of acidic stomach contents into the oesophagus can lead to chronic heartburn, inflammation (Barrett's oesophagus), ulcers and narrowing and, in the longer term, Barrett's carcinoma
In the past, operations on the oesophagus were performed using an open surgical technique, i.e. the abdominal cavity (laparotomy) and chest cavity (thoracotomy) had to be opened. The open surgical procedure can be associated with high surgical trauma and therefore pulmonary (lung) complications in particular and an increased risk of death.
These complication risks can be minimized with minimally invasive surgery. For this reason, partially (hybrid technique) or completely minimally invasive procedures are now considered the gold standard in esophageal surgery.
Procedures that are used in esophageal surgery are, for example
- Laparoscopic (i.e. using laparoscopy) correction of a hiatal hernia
- Open or minimally invasive procedures for diaphragmatic hernias, often using a plastic mesh
- Endoscopic dilation (so-called pneumatic balloon dilatation) of the lower sphincter area or laparoscopic splitting of the muscles of the lower oesophagus and the stomach entrance (cardia; so-called Heller myotomy) in achalasia
- Endoscopic or minimally invasive, rarely open treatment of diverticula
- Excision (usually minimally invasive) of leiomyomas
- Superficial removal of esophageal cancer in early stages (so-called early carcinomas) as part of an esophagoscopy
- Esophagectomy (removal of the oesophagus) for advanced oesophageal cancer
- Anti-reflux surgery for gastroesophageal reflux disease: destruction of the Barrett's epithelium (pathologically altered oesophageal mucosa) using heat during an oesophagoscopy and reinforcement of the oesophageal orifice with stomach tissue during a laparoscopy(so-called laparoscopic fundoplication)
Esophagectomy and anti-reflux surgery are described in more detail below.
Esophagectomy (esophageal resection), i.e. the removal of the esophagus, is usually performed to treat esophageal cancer.
Although the first esophagus was removed from a patient with esophageal cancer as early as 1913, it was not until the 1980s that the mortality risk was reduced from the original 90 percent to 20 percent. Today, this risk is less than four to five percent - but only if the operation is performed by a qualified expert in a facility where a high number of esophageal resections are performed each year.
There are basically two procedures for removing the esophagus:
- transhiatal esophagectomy, which means removal via the opening in the diaphragm (hiatus oesophageus) through which the esophagus passes into the abdomen; this requires an abdominal incision and an incision on the left side of the neck.
- transthoracic oesophagectomy, in which the abdominal cavity and chest cavity are opened.
Both procedures can be performed using open surgery or completely minimally invasive surgery; a combination of open surgery and minimally invasive surgery is possible and is called a hybrid technique.
Transhiatal esophagectomy is usually performed as an open surgical procedure and mainly in patients with impaired lung function. It is a treatment option in particular for tumors located in the lower third of the esophagus. However, due to the slightly better chance of survival, transthoracic esophagectomy is preferred by many centers, especially as a minimally invasive procedure(thoracoscopic-laparoscopic esophagectomy), where the complication rate is lower compared to the open procedure. The hybrid technique is often used in difficult cases.
After removal of the oesophagus, the function of the food passage is achieved by reshaping part of the stomach into a tube and connecting it to the remaining oesophagus. If the stomach also has to be removed, part of the large intestine or, more rarely, the small intestine can be used to replace the removed esophagus.
Thoracoscopic-laparoscopic surgery, i.e. a minimally invasive procedure on the abdominal cavity and thoracic cavity, begins in the supine position. Using special endoscopic instruments, the lower oesophagus and surrounding lymph nodes are dissected through five small incisionsin the abdomen and the stomach is prepared for the restoration of the food passage.
Endoscopic instruments are then inserted into the chest in the lateral position, also via five small incisions, and the esophagus is detached from the surrounding tissue just below the passage into the neck (Fig. 2).
If the tumor is located in the neck part of the esophagus, the neck must also be dissected free. In most cases, however, the neck part of the esophagus does not need to be removed. Finally, the raised stomach tube is connected to the remaining esophagus (Fig. 3) and the detached esophagus with the lymph nodes is removed from the body.
Fig. 2 Extent of resection for cancer of the lower oesophagus
Fig. 3 Reconstruction after radical removal of the esophagus using a stomach tube
The cause of reflux is usually a hiatal hernia with the entrance to the stomach sliding up into the chest, which disrupts the valve mechanism. Consequently, the treatment consists of surgical reconstruction of the diaphragmatic hiatus, which today can usually be performed using minimally invasive techniques. The following three laparoscopic (laparoscopy) methods have become established as standard procedures, with the first being the most common and the last by far the least common:
- laparoscopic fundoplication according to Nissen
- laparoscopic fundoplication according to Toupet
- Laparoscopic fundoplication according to Dor
In these laparoscopic operations, the diaphragmatichiatus is narrowed in the first step(hiatoplasty) and in the second step the stomach dome is wrapped around the lowest part of the oesophagus in the form of a sleeve(fundoplication). This is intended to keep the esophagus stretched so that the valve mechanism functions again (Fig. 4). The three methods mentioned above differ in whether the sleeve is applied 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 diaphragmatic hiatus (hiatoplasty) and cuffing of the gastric dome around the esophagus (fundoplication)
Hiatoplasty is performed with sutures and occasionally with additional stabilization using an artificial mesh in the case of larger gaps.
The operation is successful and permanent. It should be offered to all patients
- who do not become symptom-free with medication or have to take it for the rest of their lives,
- who have severe reflux of stomach contents, or
- whose acid reflux leads to irritation of the larynx and bronchial tubes.
Three new procedures are currently promising as alternative treatment options and are being investigated in clinical trials:
- Laparoscopic insertion of a magnetic ring around the lower esophageal sphincter
- Transoral incisionless fundoplication, i.e. via the mouth and without skin incisions
- Implantation of an electrical stimulation device to improve the function of the lower esophageal sphincter
Operations on the oesophagus as part of oesophageal surgery are very stressful for patients; however, the complication rate has been steadily reduced in recent decades thanks to minimally invasive procedures.
After esophagectomy, patients have to relearn how to eat. Hunger will be absent for some time and food must be divided into several small individual portions. In principle, there is no standard diet, but each patient tries out their own options. Rehabilitation treatment lasting several weeks is suitable for this. However, the quality of life is not primarily determined by the consequences of the operation, but by the possible recurrence of the cancer.
