Esophageal cancer surgery at the Sachsenhausen Clinic, Germany, Frankfurt

Esophageal cancer surgery

The treatment of choice for esophageal cancer is surgery. Your goal is to completely remove the tumor tissue and thereby cure the disease. The scope of the operation depends on the stage of the cancer. If the tumor is still in an early stage (so-called early carcinoma) and is therefore limited only to the superficial parts of the esophageal mucosa, it may be removed endoscopically while preserving the esophagus.

In the majority of cases, however, it is necessary to completely or at least partially remove the esophagus in order to completely remove the tumor tissue and the surrounding lymph nodes. The decisive factor for the success of the operation is that the tumor can be removed with a safety margin in healthy tissue. This means that the surgeon not only removes the tumor itself, but healthy tissue beyond its borders. This is to ensure that no tumor cells remain in the body that could grow into a new tumor.

As for the removal of other organs, so-called minimally invasive procedures are becoming increasingly common in the surgical removal of the esophagus. Small incisions made using special instruments in the abdominal cavity (laparoscopic procedure) and / or the chest (thoracoscopic procedure) enable fewer complications and faster patient recovery. This even seems to have a positive impact on the overall results, that is, the chances of the patient recovering.

During the operation, the lymph nodes surrounding the tumor are always completely removed (lymphadenectomy). This happens for safety, since the tumor can spread through the lymphatic system. In addition, the microscopic examination of the removed lymph nodes can determine the actual extent of the disease.

The remaining healthy parts of the esophagus are then connected to the stomach so that the patient can continue to eat. If the stomach is not suitable as an esophageal replacement, a segment of the large intestine or small intestine is used.

The basic requirement for performing such a large and stressful operation is that the patient is in a good general condition and does not suffer from serious comorbidities.

If the tumor is no longer limited to the inner layers of the mucous membrane, chemotherapy or combined radiation chemotherapy (radiochemotherapy) is usually carried out before the operation. With the help of this supportive neoadjuvant treatment, the tumor is reduced in size and cancer cells scattered throughout the body are destroyed. The chances of success increase considerably through the additional treatment. Studies have shown that long-term survival rates in esophageal cancer are significantly improved by neoadjuvant treatment. Other studies even indicate that in some cases, if radiation chemotherapy works well, especially with squamous cell carcinoma, successful therapy is possible even without surgery. Depending on the operational risk of the individual patient, the doctor will talk to him about this option and select the treatment concept accordingly (so-called definitive (higher-dose) radiation chemotherapy).

Supportive (adjuvant) chemoradiation therapy can also be carried out after the operation. However, one advantage of this treatment has so far not been clearly proven and, moreover, has greater side effects than the therapy before the operation.

If daughter tumors (metastases) have already formed in more distant regions of the body, healing is no longer possible. Surgery would then only serve the purpose of alleviating any symptoms that may arise, or preventing or treating complications. Such a situation exists, for example, if the tumor obstructs the passage of food through its growth. However, instead of surgery, endoscopic procedures are usually used today, i.e. measures that establish the passage of food as part of a mirroring or secure nutrition via the gastrointestinal tract (placement of an esophageal stent or a feeding tube).

How are esophageal squamous cell carcinomas operated on?

If the tumor is located in the area of ​​the breast esophagus, it is removed together with the neighboring lymph nodes. The chest cavity between the ribs is usually opened from the right side. If necessary, the upper part of the stomach and the lymph nodes in the upper abdomen are removed via an abdominal incision.

If this surgical procedure is out of the question for certain reasons, e.g. B. because the patient is in poor general condition and the tumor is predominantly in the lower third of the esophagus, another procedure can be used: the so-called blunt removal of the esophagus. In this case, the esophagus is only removed from the abdomen and neck. Since the chest cavity is not opened, the removal of the lymph nodes in the upper chest must be avoided.

When part of the esophagus is removed, the connection to the gastrointestinal tract is broken. In order for the patient to be able to eat again, this connection must be reestablished in the second part of the operation. The stomach transformed into a tube serves as an esophageal replacement. It is connected to the part of the esophagus that remains in the chest or neck. If the stomach is too short due to previous surgery, part of the large intestine or small intestine can also be used as an esophageal replacement. This also applies if the tumor is very high up in the esophagus.

How are esophageal adenocarcinomas operated on?

Adenocarcinomas are often confined to the lower section of the esophagus. In favorable cases, they can therefore be operated on from the abdominal cavity without opening the chest. During this operation, the surgeon also removes the upper part of the stomach and the corresponding lymph nodes. In this case, too, the food path is restored through the tubular stomach or through a piece of the large intestine.

If the carcinoma is located higher up in the esophagus, the tumor is removed via an opening in the chest, as in squamous cell carcinoma.

With very small tumors in the lower part of the esophagus, partial removal of the affected section of the esophagus is also possible in rare cases. A short piece of small intestine is used to restore the connection.

Endoscopic surgical methods

For some years now it has been possible to remove small tumors that are limited to the mucous membrane using endoscopic procedures. The tumor is removed via an endoscope with an electrical loop or an electrical knife. However, endoscopic procedures can only be used in very early tumor stages, i.e. only if the superficial mucosa is affected and no lymph node metastases are to be expected. Such an early diagnosis is very rare for this tumor.

Treatment after surgery

If the tumor can be completely removed by the operation, no further therapy is usually necessary.

If the tumor could not be completely removed in the healthy, it is possible to carry out combined radiation chemotherapy (radiochemotherapy) after the operation. The aim of this additional treatment is to destroy the tumor tissue remaining in the body or to prevent it from growing again. However, it is not certain whether this will reduce the risk of relapse or extend life.

Prof., Dr. med. Plamen Staikov

Prof., Dr. med. Plamen Staikov

Medical Director, Head physician

Holger Bahn

Holger Bahn

Senior physician

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