Oesophageal surgery, i.e. surgery on the oesophagus, is mainly used for reflux disease and oesophageal cancer. Oesophageal surgery is a complex challenge for the surgeon. Nowadays, oesophageal surgery is being performed less and less openly and more and more frequently using minimally invasive techniques. Here you will find further information as well as selected specialists and centers for esophageal surgery.
The oesophagus connects the mouth to the stomach and runs through the throat, chest and abdomen. It is an almost 30 cm long muscular tube that serves solely to transport liquid and solid food.
This transportation is an active process and takes place through reflexive wave-like contractions.
The transition from the esophagus to the stomach takes place via an oblique orifice that acts like a valve. This passively prevents the backflow (reflux) of acid and food from the stomach.
Fig.1: Schematic anatomy of the esophagus. It passes through the throat, chest and, after passing through a gap in the diaphragm, the abdominal cavity.
The oesophagus begins at the pharynx. From there it runs behind the trachea through the neck into the back of the mid-chest. Here it runs in the upper part behind the trachea and in the lower part behind the heart.
Below this, it runs together with the large abdominal aorta through a gap at the back of the diaphragm into the abdominal cavity. Here it is less than 5 cm long and joins the entrance to the stomach at an acute angle.
The muscular wall of the esophagus has a two-layer structure: Circular on the inside and longitudinal on the outside.
Muscle contractions cause the chyme to be transported in the right direction. At the transition to the stomach opening, however, the musculature is twisted in the longitudinal axis, which causes a valve-like wring closure and prevents reflux.
Anatomy of the stomach © Henrie | AdobeStock
While the esophagus is a fairly simple organ from a functional point of view, it is a complex challenge from a surgical point of view. The surgeon is often forced to operate in several anatomical "rooms" (neck, chest, abdomen), which require their own access routes (skin incisions).
Esophageal surgery is center surgery! In recent years, there has been a shift from open to minimally invasive oesophageal surgery (keyhole surgery).
The list of diseases of the esophagus is long:
This article discusses the two main surgical diseases of the esophagus: acid reflux and esophageal cancer.
The digestive process in the stomach begins with gastric acid. The stomach lining is resistant to the aggressive hydrochloric acid. However, that of the oesophagus is not. The oesophagus is protected from acid reflux by a functional valve.
If the valve is defective, this reflux of stomach acid into the oesophagus can cause
cause. In some cases, these symptoms can cause further illnesses after many years of chronic reflux. These include cellular remodeling of the oesophagus(Barrett's mucosa, dysplasia) or cancer.
The permanent suppression of gastric acid production with medication can successfully relieve reflux symptoms in many patients.
However, once cellular remodeling has been initiated, the process of cancer development can probably no longer be stopped with medication. This is why regular endoscopic check-ups(gastroscopy) and preventive care are necessary.
Healthy stomach (left) and stomach with reflux disease (right) © bilderzwerg | AdobeStock
Oesophageal cancer is a malignant growth of the mucous membrane (epithelium).
There are two variants:
Oesophageal cancer is very aggressive and is characterized by uncontrolled growth and rapid metastasis (spread). It spreads in length and depth.
As the wall of the esophagus measures only a few millimeters, the cancer breaks out early and infiltrates the neighboring structures. At this point, tumor cells have usually already infiltrated the widely branching lymph node network via the lymphatic system.
However, it is not a multi-stage filter station, as we know it from bowel cancer. Lymph node involvement is therefore an indicator of generalized cancer spread. This metastasis occurs primarily via the bloodstream in
Esophageal cancer is a rare cancer in the western world. The main symptom is painless dysphagia. It first affects solid foods such as bread and meat, then mushy foods and finally liquids.
Patients usually only contact their doctor once they have lost weight. Gastroscopy confirms the diagnosis of cancer, which usually presents as a typical malignant ulcer. The endoscopist takes a sample so that the pathologist can determine the exact type of cancer.
This picture shows how a gastroscopy works © bilderzwerg | AdobeStock
Once the diagnosis has been made, tumor staging begins using ultrasound and computed tomography (CT). Other examinations such as magnetic resonance imaging(MRI) or the new PET-CT are rarely required in routine clinical practice.
Valuable months often elapse between the first symptoms and the diagnosis.
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 most sensible treatment is surgical reconstruction of the diaphragmatic hiatus, which can nowadays usually be carried out using a minimally invasive procedure.
The operation is performed laparoscopically, i.e. by means of laparoscopy. This involves
Fig. 2: Laparoscopic narrowing of the diaphragmatic hiatus (hiatoplasty) and wrapping 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 fundoplication can be performed between 180-360 degrees; the latter variant is the most common (Fig. 2).
The operation is successful and the result is permanent. It should be offered to all patients who
It is not yet certain whether the cancer development described above can be interrupted or even reversed by the operation.
The treatment of esophageal cancer depends on
Only rarely are carcinomas discovered at an early stage. These are usually patients who are being monitored due to chronic reflux.
Early carcinoma of the esophagus is curable. If it is limited to the mucous membrane, the cancer can be removed endoscopically using special techniques as part of oesophageal surgery. If the early carcinoma penetrates deeper into the wall of the oesophagus, surgery is required.
However, most esophageal cancers have already metastasized to the lymphatic system and other organs at the time of diagnosis. A cure then comes too late.
In this palliative situation, operations are only performed to ensure nutrition (e.g. feeding catheter in the intestine). Nowadays, such operations are rarely necessary, as this goal can usually be achieved endoscopically. If the cancer causes a narrowing, this can be opened using a laser and stent.
Feeding tubes can often also be placed endoscopically in the stomach. In the case of generalized cancer, oncologists try chemotherapy to slow down the growth and alleviate the cancer symptoms.
In the case of squamous cell carcinoma, additional radiation can usually significantly reduce the size of the tumor.
In the stage between early carcinoma and generalized spread, modern medicine uses maximum therapy. The prerequisite is that the patient is in good general health.
In recent years, a differentiated multimodal treatment concept has emerged - analogous to rectal cancer. Patients should therefore be treated in cancer centers by a team of specialists.
Squamous cell carcinomas of the upper oesophagus are almost exclusively treated with radiotherapy. In addition, a reinforcing chemotherapy is used.
Esophageal surgery is only rarely used. The entire oesophagus, including the lymph nodes, is removed from the neck to the stomach. The stomach is then moved through the chest into the neck, where it is connected directly to the gullet.
This complex oesophageal surgery is extremely stressful and dangerous for the patient. For this reason, radiotherapy is usually preferred.
Illustration of esophageal cancer and upward displacement of the stomach © bilderzwerg | AdobeStock
Tumors of the lower oesophagus are primarily operated on if they have not metastasized to the lymphatic system or other structures.
Adenocarcinomas are usually located directly above the stomach in the abdominal cavity. In this case, a diagnostic laparoscopy is often necessary to precisely determine the spread in the abdomen.
If the oesophageal cancer has broken through the wall, neoadjuvant pre-treatment is used nowadays. This involves chemotherapy for around three months. Only then is surgery followed by chemotherapy.
In the case of squamous epithelium, radiotherapy can also be used before surgery.
The exact treatment plan is determined by the specialist team for each individual patient.
Oesophageal surgery is mainly used for cancer of the lower oesophagus. The aim is to radically remove the oesophagus with the cancer and the surrounding soft and lymphatic tissue. These are internationally standardized operations (Fig. 3,4).
Access is via an abdominal incision. The esophagus is now dissected from the diaphragm together with the lymphatic drainage area along the small gastric curve to the abdominal aorta.
A tube is formed from the remaining stomach, which acts as an esophageal replacement. The chest is then opened (usually on the right). The surgeon removes the oesophagus in the thorax together with the lymphatic ducts of the posterior thorax.
The gastric tube is moved through the diaphragmatic hiatus into the posterior chest. There, the surgeon connects it to the esophageal remnant in the upper chest, which is done mechanically using staplers. This complex two-cavity operation (Ivor-Lewis operation), which lasts several hours, is only performed in large hospitals.
Fig. 3: Extent of resection for cancer of the lower oesophagus
Fig. 4: Reconstruction after radical removal of the esophagus using a stomach tube
A cure is only achieved after esophageal surgery if all tumor tissue has been removed or destroyed. This is followed by a phase of recovery and adaptation of the organism to the newly reconstructed anatomy, which can take several months. After this, a completely normal life without restrictions is possible.
It is often only clear whether complete removal of the primary tumor was possible after examination of the removed tissue.
If even microscopically tiny metastases are found in the lymph nodes, the chance of recovery is drastically reduced - despite the enormous therapeutic efforts. The prognosis is then poor and the cancer returns within one to two years. It then appears either as a local recurrence in the chest or as distant metastases in the liver, lungs or bones.
There is no specific treatment in this situation. Instead, it is based on the individual symptoms such as pain or food intake. This is why there is no standardized oncological aftercare for oesophageal cancer. Instead, medical and nursing care is palliative in nature.
Operations on the oesophagus as part of oesophageal surgery are traditionally very stressful for patients. However, the complication rate has been steadily reduced in recent decades.
More and more centers are no longer performing open surgery. Minimally invasive access through small incisions (keyhole technique) is expected to result in less stress and faster recovery from the operation.
Patients have to relearn how to eat after the operation. 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.
In advanced cancer, a cure can only be achieved through a combination therapy of surgery, chemotherapy and possibly radiotherapy. Other drugs are used to alleviate symptoms, especially pain.
The Leading Medicine Guide's quality assurance is ensured by the following acceptance prerequisites.
