Esophagectomy is performed by surgeons at Massachusetts General Hospital as both a minimally invasive and standard open procedure to remove a diseased esophagus and reconstruct the gastrointestinal tract.
Esophagectomy is a surgical procedure that involves removing part of, or the entire, diseased esophagus (the tube that connects the mouth and the top part of the stomach). A portion of the stomach is then pulled up into the chest and connected to the remaining, healthy portion of the esophagus or pharynx (throat), creating a new esophagus. Massachusetts General Hospital is one of the few facilities in Boston offering minimally invasive esophagectomy, in addition to standard open esophagectomy.
Virtually all patients who need an esophagectomy are candidates for the minimally invasive, or laparoscopic, procedure. Specialists in the Gastroesophageal Surgery Program work closely with the Swallowing and Heartburn Center at the Mass General Digestive Healthcare Center, as well as patients and referring physicians, to determine the treatment plan that is best for each patient.
How is Esophagectomy Performed?
Minimally Invasive Esophagectomy
Minimally invasive esophagectomy (MIE) is completed with small incisions rather than separating the ribs or making a large incision, as in standard surgery. Surgeons performing this surgery place a tiny camera in the patient’s abdomen and chest. Images from the camera are transferred to a monitor, and the procedure is completed using these video images. A thorough inspection is made to ensure that the disease has not spread to other parts of the body.
During the procedure, the diseased esophageal tissue is removed (which may include any surrounding cancerous tissue and adjacent lymph nodes), and part of the stomach is then used to rebuild the esophagus. The operation, whether performed minimally invasive or open, typically takes between four and six hours.
Standard Open Esophagectomy
An open esophagectomy can be performed using a variety of techniques. Although the open operations are similar to a minimally invasive approach in that the esophagus is removed and reconstructed with the stomach, an open approach involves opening the abdomen with a large incision and spreading of the ribs. This is a safe approach, and for patients with cancer, results are similar between MIE and open procedures.
What Preparation is Required Prior to an Esophagectomy?
Before an esophagectomy, most patients undergo imaging procedures, such as computed tomography (CT) or positron emission tomography–computed tomography (PET/CT), and an assessment of cardiovascular fitness. Patients also meet with an anesthesiologist prior to the procedure. The preoperative testing is similar before either an MIE or open procedure.
If the procedure is being performed for cancer, the patient often has met with an oncologist, and may have received chemotherapy and radiation.
What is the Recovery Time and Follow-Up?
Minimally Invasive Esophagectomy
Patients spend one night in the intensive care unit after surgery. Most patients are then moved to an inpatient hospital room for about seven days.
Patients should expect six to eight weeks of recovery and adjustment in eating patterns after the procedure. Most patients benefit from eating smaller, more frequent meals after esophagectomy. In addition, patients may benefit from sleeping slightly elevated on pillows or a small wedge.
Most patients can expect to eventually return to all normal activities following an esophagectomy. During the recovery period, patients are encouraged to walk as much as possible to regain strength and endurance.
Patients typically return to Mass General two to four weeks following the procedure for follow-up. For patients with esophageal cancer, we work with your care team to determine how to best monitor your health after the procedure.
Standard Open Esophagectomy
Compared to the MIE procedure, the recovery period following an open esophagectomy may be slightly slower, but with a similar estimated length of hospital stay.
Who is Eligible for an Esophagectomy?
Esophagectomy may be recommended for patients with the following conditions:
- Some benign (non-cancerous) conditions of the esophagus, including advanced achalasia (a rare digestive disorder that occurs when the muscle at the bottom of the esophagus that normally functions as a valve fails to relax, preventing food from entering the stomach) and effects from some revisional anti-reflux procedures
- Barrett's esophagus
- Esophageal cancer
How Safe is the Procedure?
There are risks with any significant procedure. However, many studies have demonstrated that outcomes are better in hospitals, such as Mass General, that perform a high volume of procedures. These risks will be outlined by a surgeon in detail prior to performing any surgical procedure.
Research published by the Mass General Division of Thoracic Surgery has demonstrated that patients undergoing a minimally invasive esophagectomy (compared to standard open esophagectomy) have fewer respiratory complications and a shorter length of stay at the hospital, leading to a faster recovery. Research has further shown that results of standard and minimally invasive esophagectomies are equivalent in regards to oncologic outcomes or cancer survival.
Esophagectomy for Barrett's Esophagus
Barrett’s esophagus is a condition affecting the lining of the esophagus, which could lead to cancer. Once Barrett's esophagus progresses to cancer, removal of the esophagus may be necessary.
Historically, surgery has been used for certain non-cancer stages of Barrett's esophagus (high-grade dysplasia) in an effort to avoid operating on more advanced cancer stages of this disease. However, in the last five years, most high-grade dysplasia patients and even early cancer patients have been treated with endoscopic therapy rather than surgery.
The Mass General Barrett's Esophagus Treatment Center has expertise in both endoscopic forms of treatment (endoscopic mucosal resection, radiofrequency ablation and cryotherapy) and surgical therapies (esophagectomy).
Patients with more advanced forms of Barrett’s esophagus, high-grade dysplasia (HGD) and/or early cancer (intramucosal carcinoma) often ask which form of therapy is recommended. There are no studies comparing the effectiveness of endoscopic therapy and surgery in these patient subsets. Studies which compare outcomes from these treatments have shown that at five years after treatment for HGD or early cancer, endoscopic therapy, when performed in expert centers, is as effective and safe as surgery.
The decision to proceed with endoscopic therapy or surgery involves many factors including patient age, coexisting medical conditions and patient preference. At the Mass General Barrett's Esophagus Treatment Center, patients with HGD or early cancer are often evaluated by both gastroenterologists and surgeons to help make the most informed decision for each patient.
Bob Hazelton lived with chronic acid reflux for years and was diagnosed with esophageal cancer in 2011. After his surgical team at Massachusetts General Hospital performed a minimally invasive esophagectomy, Bob has a healthy esophagus and is getting back to his active lifestyle.
Minimally invasive esophagectomy (MIE) is a procedure performed by Massachusetts General Hospital surgeons using small incisions to remove a diseased esophagus and reconstruct the gastrointestinal tract. For more information, visit massgeneral.org/MIE