Esophageal Cancer Surgery

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Send the endoscopy report with the tumour distance from the teeth

How far down the gullet the tumour sits decides which operation is proposed and where the join ends up, and endoscopists record that distance in centimetres from the front teeth. Send that report, the biopsy including HER2 and PD-L1 where they were done, the staging CT and PET as image files, the endoscopic ultrasound if one was performed, and your weight now against six months ago. What comes back is an opinion on whether resection is realistic, whether chemotherapy or chemoradiotherapy should come first, and what eating would look like a year from now. The review costs nothing and carries no obligation.

The stomach becomes the gullet

Your oesophagus is a muscular tube with no spare length and no substitute. Take a section out and the two ends cannot be brought together, so something else has to bridge the gap, and in almost every case that something is the stomach. Surgeons divide it along its length into a narrow tube perhaps four centimetres wide, keeping one artery that runs up its right side, and that tube is then lifted through the chest to reach the remaining gullet.

Four consequences follow immediately, and every one of them is permanent.

Sitting in the chest, the stomach no longer holds a meal. Its capacity after tubularisation is a fraction of what it was, so meals become small and frequent and stay that way. The valve at the top of the stomach that stopped acid rising is gone, removed with the specimen, so reflux is now unopposed and gravity is the only thing preventing it, so sleeping flat becomes impossible. The nerve that told the stomach to empty is divided during the dissection, so a drainage procedure at the outlet is added to compensate. And the new tube sits inside the chest, so breathing and eating interfere with each other in ways nobody predicts, since a full conduit presses on a lung that has just been through an operation of its own. That is the operation working as designed, and understanding it in advance is the difference between a patient who adapts and one who spends a year assuming something has gone wrong.

None of that is a complication.

Almost nobody operates first

Outside the earliest tumours, surgery alone has not been standard treatment for more than a decade. Chemoradiotherapy comes first for most patients, and the trial that established it has now reported ten years of follow-up.

Five weeks of treatment. Then six to eight weeks of recovery. Then surgery. That timetable does more than anything else to disrupt the plans for somebody arranging treatment across borders, and it has to be settled before anybody books a flight.

Where the specimen still contains viable cancer despite the chemoradiotherapy, a year of immunotherapy improves the odds. A trial of 794 such patients found median disease-free survival of 22.4 months with the drug against 11.0 months with placebo, a hazard ratio of 0.69, at a cost of serious side effects in 13 percent against 6 percent. What the pathologist finds decides that treatment, which means the pathology report from your operation determines a year of your treatment and has to travel home with you in a form an oncologist can act on within weeks rather than months.

Where the incisions go

Oesophagectomies take their names from the body cavities the surgeon has to enter, and the tumour's height decides that. A tumour low down near the junction with the stomach can be reached through the abdomen and the right chest. One higher up needs the neck opened as well.

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Access has now been tested properly. A Dutch trial randomised 112 patients to robotic minimally invasive oesophagectomy or open surgery through the chest, and found overall surgery-related complications in 59 percent of the robotic group against 80 percent of the open group. Pulmonary complications fell by nearly half, cardiac complications by more than half, blood loss was lower, pain scores were lower and both functional recovery and quality of life were better. Cancer outcomes were the same at forty months.

So where a unit offers it competently, minimally invasive surgery is the better version of the same operation. Where it does not, an open oesophagectomy performed well by somebody who does forty a year beats a keyhole one performed by somebody learning.

Neck or chest, and why it matters

Joining the stomach tube to the remaining oesophagus is the decision with the longest reach, and it produces two genuinely different recoveries.

Joins in the neck are easier to reach if they leak. The wound can be opened at the bedside, the leak drains outwards through the skin, and although it is unpleasant it is rarely life-threatening. A join inside the chest is more difficult to reach and a leak there spills into the chest cavity, which is a far more serious event. That argues for the neck.

Set against it, the nerve that supplies the voice box runs alongside the oesophagus in the neck and is at real risk during that dissection.

A hoarse voice and a weak cough are not trivial after an operation where the ability to clear your chest determines whether you develop pneumonia. That is the trade. Where the tumour sits low enough to allow either, most units now prefer the chest.

The operation, in order

Four to eight hours, in two or three separate stages with the patient repositioned between them.

Between a fifth and a third of patients booked for this operation turn out to need something different once the abdomen or chest is inspected, and that possibility belongs in the conversation before anybody travels.

The first two weeks

What surprises people most is that you do not eat. Published practice keeps patients off oral intake for the first five to seven days at minimum, and many units wait ten days to two weeks and confirm with a contrast swallow that the join is watertight before allowing anything by mouth.

Nutrition continues throughout, delivered into the small bowel through the feeding tube placed during the operation, beginning on day two or three. That tube does not count as an afterthought. A cohort study comparing patients who had one against those who did not found weight loss at two weeks of 3.2 percent against 7.2 percent, and a hospital stay of eleven days against fifteen.

1. Days one and two in intensive care, sitting up, with the chest drain on suction and physiotherapy starting immediately.
2. Days two to four, feeding into the small bowel begins and builds, the epidural comes down onto tablets, and you walk further each day.
3. Days four to seven, the chest drain comes out once it is dry and the lung is up, and the nasogastric tube usually follows.
4. Around days seven to ten, a contrast swallow or a scan checks the join before anything is allowed by mouth.
5. Days ten to fourteen, sips build to free fluids and then to a soft diet, with the feeding tube still supplying most of your calories.

Many people go home with that feeding tube still in place and use it overnight for weeks, which sounds worse than it is and prevents the weight loss that otherwise takes months to reverse.

What goes wrong

Oesophagectomy has one of the highest complication rates in elective surgery, and the trial comparing robotic with open surgery is instructive on the scale of it. Even in the better arm, 59 percent of patients had a complication of some kind.

The lungs, first and worst

Chest problems dominate. Pneumonia, collapse of the lung base, and fluid collecting around the lung together account for more trouble than everything else combined, which is why the physiotherapist appears within hours and why the pain relief exists to let you cough rather than to keep you comfortable lying still.

The join, and everything after it

Anastomotic leak comes next and it is the one that defines the operation. It appears between day five and day ten. A neck leak drains outwards and is managed by opening the wound. A chest leak is drained by a radiologist or by a stent placed endoscopically across it, and occasionally needs a return to theatre. Most heal, and the price is weeks rather than days.

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Two more deserve naming. Atrial fibrillation follows any operation inside the chest commonly enough and usually settles on medication. Conduit necrosis, where the new stomach tube loses its blood supply altogether, is rare and is the reason some units check the perfusion with fluorescent dye before committing to the reconstruction.

Death within 90 days is meaningfully higher after this operation than after most cancer surgery, and it falls sharply with hospital volume, which makes the annual number of oesophagectomies a reasonable thing to ask about directly.

Eating, sleeping and reflux

Five years from now, this is the section that will have mattered, and it follows directly from the first section of this page.

Small, often, and slowly

Tubularised, the stomach holds a fraction of what it held, so six to eight small meals replace three and that pattern is permanent rather than a phase of the recovery. Eat slowly and chew thoroughly, since the conduit has no muscular squeeze of its own and food travels down largely by gravity. Sit upright for a meal and stay upright for an hour afterwards. Expect some foods to stick early on, particularly bread, dry meat and anything fibrous, and expect that to improve steadily across the first six months as the conduit settles and you learn what it will take. Dumping happens here too, when a meal rich in sugar arrives in the small bowel too quickly, producing sweating, cramps, palpitations and diarrhoea within half an hour of eating. Cutting simple sugars and putting protein and fat into each meal handles most of it, and a dietitian who has managed this before is worth more here than any amount of reading about it.

The bed, and the night

The valve that kept acid out of the oesophagus was removed with the tumour, so nothing now stops stomach contents rising except gravity. Lie flat and they reach the throat and the airway. Inhaling them at night causes coughing, hoarseness and occasionally pneumonia. Raise the head of the bed by fifteen to twenty centimetres on blocks rather than piling up pillows, which only bends you at the waist and makes it worse. Stop eating three hours before lying down. Acid suppressing medication is prescribed at discharge and continued indefinitely, since the anatomy that made it necessary is permanent and no amount of time will restore the valve that was removed. Four habits do most of the work here, and all of them are about position and timing rather than about which foods you choose, which is the part patients expect to be told and the part that matters least.

1. Raise the head of the bed on blocks by fifteen to twenty centimetres. Not on pillows.
2. Finish eating three hours before you lie down, and keep the last meal small.
3. Sit upright to eat and stay upright for an hour afterwards, including on aeroplanes and in cars.
4. Take the acid suppressing medication continuously and expect to stay on it.

Weight falls and then settles. Ten to fifteen percent is common in the first six months, and stopping the fall matters far more than reversing it, since the treatment that follows is given to people strong enough to receive it. Weigh yourself weekly and write the number down, because a downward trend is far easier to see on paper than in a mirror, and far easier to reverse in month two than in month six.

How long you stay

Five to six weeks in the country for the surgery alone, which is longer than for any other operation described on this site and is not padding.

Assessment takes five to seven days. Endoscopy repeated with the distance from the teeth recorded, staging CT and PET, endoscopic ultrasound where the depth is uncertain, lung function testing and an echocardiogram since the chest is being opened, nutritional assessment, and a tumour board before a date is fixed. Where chemoradiotherapy is given first, the whole timetable shifts by roughly three months and needs planning as two trips or one long stay.

Expect ten to sixteen days on the ward when nothing goes wrong, beginning with one or two nights in intensive care. Add a further two weeks nearby afterwards, which covers the swallow test if it has not already happened, the transition from tube feeding to oral intake, the pathology discussion that decides the immunotherapy question, and the dietitian sessions that make the difference between coping and not.

Flying gets cleared at around four to five weeks, with drains out, no fever, no undrained collection, a lung that is fully up on the X-ray, an oral intake that is holding your weight and a written plan for clot prevention. A long flight sitting upright is easier than most people fear. Lying back is the problem, so book a seat you can keep raised.

What drives the cost

Two or three body cavities, a stapler-heavy reconstruction and a planned intensive care stay put this operation among the most expensive on any hospital list. Eight things move the total.

1. Which operation is planned. A three-stage McKeown occupies a theatre considerably longer than a two-stage Ivor Lewis does.
2. The approach, because robotic and thoracoscopic platforms carry per-case instrument costs that open surgery does not.
3. The stapler cartridges the conduit and the join consume, which is a real and substantial line item here.
4. Intensive care nights, which are planned rather than exceptional after this operation.
5. Ward days, which the chest and the join decide between them and which nobody can promise in advance.
6. Endoscopic or radiological treatment of a leak, stent included, which a meaningful minority of patients turn out to need.
7. Feeding tube supplies and dietitian input, which continue after discharge and are frequently uncosted.
8. Chemoradiotherapy before and immunotherapy after, which together exceed the surgical cost and sit outside almost every package.

Arriving underweight, with poor lung function, with heart disease, still smoking, or having already had radiotherapy to the chest each raise the chance of a longer stay and of care nobody planned for.

Packages published here ordinarily cover the transfers, the pre-admission workup, the operating fees, an agreed count of theatre and ward days, an interpreter, accommodation and the appointments before departure. Sitting outside it, almost always, are the flights, insurance, ward nights past the agreed count, unplanned critical care, the treatment of a leak and all drug therapy.

Six questions turn a headline into a quotation. Which operation does the figure assume, named by the number of stages it has. What number of intensive care nights sits inside it. How many ward nights, and the price of an extra one. Is endoscopic stenting for a leak covered. Are the feeding tube supplies included after discharge. And whether the specimen pathology, which determines whether you need a year of immunotherapy, sits inside the figure.

No quotation means anything until a surgeon has read your endoscopy and your scans. That review costs nothing.

Once you are home

One document decides the next year of your treatment. If the pathologist found viable cancer left in the specimen after chemoradiotherapy, you are a candidate for a year of immunotherapy that lengthened median disease-free survival from 11.0 to 22.4 months in the trial that established it. An oncologist at home cannot make that decision without the report in front of them.

Take home the operative note naming the operation and where the join sits, the full pathology with the response to treatment and the node count, the imaging on disc, your discharge weight, the feeding tube instructions if one is still in place, and the name of somebody here who answers messages. Get it in English before you leave the building.

Surveillance runs on clinical review and CT every six months for the first two to three years, with endoscopy where symptoms call for it. Difficulty swallowing that returns is investigated promptly, since a benign narrowing at the join is far commoner than a recurrence and is fixed by stretching it at endoscopy.

Get in touch here for a fever, chest pain, breathlessness, food sticking, vomiting, a cough that starts at night, or weight that is still falling at three months. A message answers most questions within hours.

Frequently asked questions about oesophageal cancer surgery