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What is esophagectomy?

Esophagectomy (surgical removal of the esophagus) is typically ONLY recommended as a treatment for high-grade dysplasia or cancer in Barrett's esophagus. This is because most patients who have Barrett's esophagus never develop cancer and the risk of complications from the surgery is too great to justify removing the esophagus of all patients who have Barrett's esophagus.

In patients who have high-grade dysplasia, the goal of surgery is to remove all of the Barrett's lining to completely eliminate the risk of developing a large and incurable esophageal adenocarcinoma (Barrett's associated cancer). Additionally, if the patient is found at surgery to have an unsuspected cancer, early surgical treatment gives the patient the best chance for cure and the only treatment that allows patients to safely stop endoscopic biopsy surveillance because all of the Barrett's lining at risk for cancer is removed along with the esophagus. The diagnosis of high-grade dysplasia should always be confirmed by an experienced GI pathologist prior to recommending esophagectomy as treatment for high-grade dysplasia.

Because not all patients who have high-grade dysplasia develop cancer when followed for many years by endoscopic biopsy surveillance, other options for these patients include ablation therapies or remaining in endoscopic biopsy surveillance without treatment. All patients who elect either of these options should undergo frequent endoscopic biopsy surveillance and if cancer is detected, esophagectomy is usually recommended. Strong consideration should be given to referring all patients with a diagnosis of high-grade dysplasia to a large specialty center that has esophageal surgeons and gastroenterologists experienced in the management of these patients.

In patients who have esophageal cancer without metastatic disease (spread of cancer to other organs) and who are good surgical candidates, surgery is performed with the intention of a possible cure and to allow the patient to swallow. In some patients,  chemotherapy and radiation therapy may also be recommended. Most patients who have developed esophageal cancer come to the doctor because they are having problems swallowing food. Very few patients who develop esophageal cancer were in an endoscopic surveillance program and had their cancer detected early. Patients who have surgery for a cancer found in Barrett's esophagus have all of the Barrett's lining removed as well as the cancer to eliminate the risk of developing another cancer in the future or missing an unsuspected second cancer that can also be present in the Barrett's tissue.

Surgical techniques

Two commonly performed surgical techniques are the "transhiatal esophagectomy" and the "transthoracic esophagectomy" (Ivor-Lewis Procedure). Both of these surgeries involve removing the patient's esophagus and top part of the stomach. A portion of the stomach is then pulled up into the chest and connected to the remaining normal portion of the esophagus. The patient then has a "new" esophagus made up of the normal portion of the esophagus not removed at surgery connected to a portion of the stomach pulled up into the chest.

Both of these esophagectomy surgeries have similar cure rates and complication rates and these should be discussed with the surgeon prior to the operation. There are advantages and disadvantages in using either surgical technique. In general, the type of surgery performed depends on many factors. Some of these factors are: age of the patient; size and location of the cancer; whether the cancer has grown into other structures in the chest, such as the lungs or large blood vessels; overall health of the patient, and even the experience of the surgeon in performing a particular surgical technique. Therefore, the type of surgery chosen should be individualized to meet the needs of the patient being treated. It is desirable for the surgeon to be flexible and experienced with both techniques.

Some centers are now performing minimally invasive esophageal surgery. Minimally invasive esophageal surgery may offer the advantage of a quicker recovery and fewer complications, but , how it compares to conventional surgical techniques is unknown. The experience in performing this procedure is limited to very few specialty centers. Studies comparing minimally invasive surgery to conventional esophagectomy with longer follow-up are needed to confirm that there are advantages of minimally invasive esophagectomy as compared to conventional esophagectomy. At the present time, conventional surgical approaches remain the standard operations in most specialty centers.

Surgeon experience and rate of mortality

Several large studies now confirm that whether a patient has a good result from the esophagectomy surgery is highly dependent on the number of esophagectomies performed at the medical center where the surgeon operates. In the hands of an experienced esophageal surgeon who performs these surgeries in a center experienced in the care of patients who undergo esophagectomy, the mortality (rate of death) is around 3-8%. On the other hand, the surgical mortality in low volume centers is in the range of 16-23%. Because esophagectomy is a technically difficult surgery, the surgeon needs to be a specialist in esophageal surgery and be regularly performing these procedures in a medical center with experience in the care of these patients. Therefore, one should undergo esophagectomy only in the hands of an EXPERIENCED esophageal surgeon who has a surgical mortality of no greater than 5% and who is regularly performing these procedures in a large specialty center.

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