Esophageal Surgery: Information & Specialists in Esophageal Surgery

The esophagus connects the mouth to the stomach, passing through the neck, chest, and abdomen. It is a muscular tube nearly 30 cm long that serves solely to transport liquid and solid food.

This transport is an active process and occurs through reflexive, wave-like contractions.

The transition from the esophagus to the stomach occurs via an oblique opening 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 neck, the chest, and, after passing through an opening in the diaphragm, into the abdominal cavity.

The esophagus begins at the pharynx. From there, it runs behind the trachea through the neck into the posterior part of the middle chest. Here, its upper portion lies behind the trachea and its lower portion behind the heart.

Below this point, it passes through a posterior opening in the diaphragm into the abdominal cavity, together with the aorta. Here, it is less than 5 cm long and enters the stomach at an acute angle.

The muscular wall of the esophagus has a two-layered structure: circular on the inside and longitudinal on the outside.

Muscle contractions cause the food bolus to move forward in a directed manner. At the junction with the stomach opening, the musculature is twisted along the longitudinal axis. This creates a valve-like twist closure that prevents backflow.

Anatomy of the Stomach © Henrie | AdobeStock

While the esophagus is a relatively simple organ from a functional perspective, it presents a complex challenge from a surgical standpoint. 

The surgeon is often forced to operate in multiple anatomical regions (neck, chest, abdomen). Each region requires its own access route (incisions).

In recent years, there has been a shift from open to minimally invasive esophageal surgery (keyhole surgery).

The list of esophageal diseases is long:

• Malformations
• Inflammation
• Tumors
• Injuries

This article focuses on the two main surgical conditions of the esophagus: 

• acid reflux and 
• esophageal cancer

Definition: Reflux Disease

The digestive process begins in the stomach with stomach acid. The stomach lining is resistant to aggressive hydrochloric acid. The esophagus, however, is not. The esophagus is protected from acid reflux by a functional valve.

If this valve is defective, the reflux of stomach acid can cause the following symptoms:

• Heartburn
• Inflammation
• Ulcers and
• Narrowing

In some cases, these symptoms can lead to further health problems after many years of chronic reflux. 

These include, for example:

• cellular changes in the esophagus (Barrett’s esophagus, dysplasia) or 
• cancer

Long-term suppression of stomach acid production with medication can successfully relieve reflux symptoms in many patients.

However, once cellular changes have begun, the process of cancer development can no longer be halted with medication. 

Therefore, regular endoscopic monitoring (gastroscopy) and screening are necessary.

Healthy stomach (left) and stomach with reflux disease (right) © bilderzwerg | AdobeStock

Definition and Tumor Biology: Esophageal Cancer

Esophageal cancer is a malignant growth of the mucous membrane (epithelium).

There are two types:

1. the more common squamous cell carcinoma, whose main causes are nicotine and alcohol, and
2. adenocarcinoma, which is caused by chronic acid reflux from the stomach (see above).

Esophageal cancer is very aggressive and is characterized by uncontrolled growth and rapid metastasis (spread). It spreads both longitudinally and deep into the tissue.

Since the wall of the esophagus is only a few millimeters thick, the cancer breaks through early and infiltrates neighboring structures. By this point, tumor cells have usually already entered the lymphatic system and spread to the lymph node network.

However, it does not follow the multistage filtration process we are familiar with in colorectal cancer. 

Lymph node involvement is therefore an indicator of generalized cancer spread. 

This metastasis occurs primarily via the bloodstream to:

• Liver
• Bones
• Lungs
• Brain

Diagnosis and Symptoms of Esophageal Cancer

Esophageal cancer is a rare form of cancer in the Western world. The primary symptom is painless difficulty swallowing. This initially affects solid foods such as bread and meat, then semi-solid foods, and finally liquids as well.

Patients usually do not seek medical attention until they have experienced weight loss. 

An endoscopy confirms the diagnosis of cancer, which usually presents as a typical malignant ulcer. The doctor takes a biopsy so that the pathologist can determine the exact type of cancer.

This image shows how a gastroscopy works © bilderzwerg | AdobeStock

Once the diagnosis is made, staging of the cancer begins using:

• ultrasound and
• computed tomography (CT)

Other tests, such as magnetic resonance imaging (MRI) or the newer PET-CT, are rarely used in routine clinical practice.

Valuable months often pass between the onset of the first symptoms and the diagnosis.

The cause of reflux is usually a hiatal hernia, in which the upper part of the stomach slides up into the chest cavity. This disrupts the valve mechanism.

Consequently, the most effective treatment is surgical repair of the hiatal hernia, which can usually be performed using minimally invasive techniques today.

The surgery is performed laparoscopically, that is, using a laparoscope. 

During the procedure, doctors first narrow the hiatal opening (hiatoplasty). In a second step, they wrap the gastric dome around the lowermost part of the esophagus (fundoplication). This allows them to keep the gastric dome stretched, restoring the function of the valve mechanism.

Fig. 2: Laparoscopic narrowing of the hiatal opening (hiatoplasty) and wrapping of the gastric dome around the esophagus (fundoplication)

Hiatoplasty is performed using sutures and, in cases of larger hiatal openings, occasionally with additional stabilization using a synthetic mesh. Fundoplication can be performed at angles ranging from 180 to 360 degrees. The latter variant is the most common (Fig. 2).

The surgery is successful and the results are long-lasting.

It is suitable for patients who:

• Are not symptom-free despite medication 
• Must take medication for the rest of their lives
• Have severe reflux of stomach contents
• Have acid reflux that causes irritation of the larynx and bronchi

It has not yet been established whether surgery can halt or reverse the progression of cancer.

The treatment of esophageal cancer depends on:

• Type of cancer
• Tumor stage
• Location, and
• the patient’s overall health

Doctors rarely detect carcinomas in the early stages. When they do, it is usually in patients who are undergoing checkups for chronic reflux. 

Early-stage esophageal cancer is curable. If it is confined to the mucosa, doctors can remove the cancer endoscopically during esophageal surgery. 

If the early-stage cancer has penetrated deeper into the wall of the esophagus, surgery is required.

By the time of diagnosis, most esophageal cancers have already spread to lymph nodes and other organs. A cure is then no longer possible.

In this palliative situation, surgery is performed only to ensure nutrition (e.g., a feeding tube placed in the intestine). 

Nowadays, such surgeries are rarely necessary, as this goal can usually be achieved endoscopically. If the cancer causes a narrowing, the passage can be opened using a laser and a stent. 

Doctors can also often place feeding tubes into the stomach endoscopically. In cases of widespread cancer, chemotherapy is used to slow the growth of the cancer and alleviate symptoms.

In the case of squamous cell carcinoma, additional radiation therapy can usually significantly reduce the size of the tumor.

In the stage between early-stage cancer and widespread disease, modern medicine employs the most intensive treatment available. A prerequisite for this is that the patient is in good general health.

In recent years—similar to the approach for rectal cancer—a differentiated, multimodal treatment concept has emerged. Patients should therefore be treated at cancer centers. 

Esophageal Surgery for Squamous Cell Carcinomas of the Upper Esophagus

Doctors treat squamous cell carcinomas of the upper esophagus almost exclusively with radiation therapy. Adjuvant chemotherapy is also used. 

Esophageal surgery is now rarely performed. In this procedure, doctors remove the entire esophagus, along with the lymph nodes, from the neck down to the abdomen. They then relocate the stomach through the chest into the neck, where they connect it directly to the esophagus. 

This complex esophageal surgery poses a tremendous burden and risk to the patient. For this reason, doctors generally prefer radiation therapy.

Illustration of esophageal cancer and gastric repositioning © bilderzwerg | AdobeStock

Esophageal Surgery for Cancer of the Lower Esophagus

Doctors primarily perform surgery on tumors of the lower esophagus if they have not metastasized to the lymph nodes 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 extent of the spread within the abdomen.

If the esophageal cancer has penetrated the wall, neoadjuvant treatment is now the standard approach. This involves chemotherapy for about three months. Only then is surgery performed, followed by additional chemotherapy. 

For squamous cell carcinoma, radiation therapy may also be administered before surgery.

A team of specialists determines the exact treatment plan for each individual patient. 

Esophageal surgery is primarily used for cancer of the lower esophagus. The goal is the radical removal of the esophagus along with the cancer and the surrounding soft tissue and lymph nodes. These are internationally standardized surgical procedures (Figs. 3, 4).

Access is gained through an abdominal incision. The esophagus is then dissected from the diaphragm, along with the lymphatic drainage area, following the lesser curvature of the stomach toward the abdominal aorta.

Surgeons form a tube from the remaining stomach, which serves as a replacement for the esophagus. They then open the chest (usually on the right side). The surgeon removes the esophagus in the thoracic cavity along with the lymphatic vessels of the posterior chest. 

Doctors pass the gastric tube through the opening in the diaphragm into the posterior chest cavity. There, the surgeon connects it to the remnant of the esophagus in the upper chest cavity using a stapler. 

This complex, multi-hour two-cavity operation (Ivor–Lewis procedure) is performed only in large hospitals.

Fig. 3: Extent of resection for cancer of the lower esophagus

Fig. 4: Reconstruction following radical esophagectomy using a gastric tube

A cure following esophageal surgery is achieved only if all tumor tissue has been removed or destroyed.  

This is followed by a phase of recovery and adaptation of the body to the newly reconstructed anatomy. This process can take several months. Afterward, a completely normal life without restrictions is possible.

Often, it is only after examining the removed tissue that it becomes clear whether complete removal of the primary tumor is possible.

If even microscopically tiny metastases are found in the lymph nodes, the chance of a cure is drastically reduced—despite the tremendous efforts of treatment. 

In such cases, the prognosis is poor, and the cancer returns within one to two years. It then manifests either as a local recurrence in the chest or as distant metastases in the liver, lungs, or bones.

In this situation, there is no specific treatment. Instead, care is tailored to the patient’s individual symptoms, such as pain or difficulty eating.

For this reason, there is no standardized oncological follow-up care for esophageal cancer. Instead, medical and nursing care is palliative in nature.

Surgery on the esophagus has traditionally been very taxing for patients. However, the complication rate has steadily decreased over the past few decades.

More and more centers are moving away from open surgery. Experts believe that the minimally invasive approach using small incisions (keyhole technique) will result in:

• less physical strain and 
• a faster recovery from surgery

After surgery, patients must relearn how to eat. They may not feel hungry for some time, and they must divide their food into several small, individual portions. In principle, there is no standard diet; instead, 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 the cancer recurring.

In cases of advanced cancer, a cure can only be achieved through combination therapy consisting of surgery, chemotherapy, and, if necessary, radiation therapy.

Other medications are used to relieve symptoms, particularly pain.