Surgery for oesophageal cancer (cancer of the gullet)
If the cancer is at an early stage, surgery may be used with the aim of curing the cancer. There are different types of operation to treat oesophageal cancer, depending on the size and position of the tumour, and whether or not it has spread.
I’ve found that whoever you’re talking to, whether it’s a GP, a consultant or nurse, they’re very willing to explain things.
Your doctor will discuss the most appropriate type of surgery with you. It’s important to discuss any operation fully with your doctor before it happens. You may find it helpful to make a list of any questions you have ahead of the discussion. Remember, no operation or procedure will be done without your consent. Some types of surgery may mean that you need to stay in hospital for a few weeks.
The most common type of operation is where the section of the oesophagus containing the tumour is removed (called an oesophagectomy). The remaining part of oesophagus is then reattached to the stomach. There are two main ways of doing this:
Trans-thoracic oesophagectomy - cuts are made in the abdomen and chest so that the affected part of the oesophagus can be removed.
Trans-hiatal oesophagectomy - cuts are made in the abdomen and neck to remove the affected part of the oesophagus.
During these operations, the top part of the stomach is often also removed. After the operation, your stomach will be higher than it was before - above (instead of below) the sheet of muscle that divides the chest from the abdomen (the diaphragm). This may affect your eating.
If it’s not possible to join your stomach to the remaining part of the oesophagus, a section of your large bowel (colon) may need to be removed to replace the part of the oesophagus that has been removed. Your doctors will explain this in more detail if they think this type of surgery may be used.
During your operation the surgeon will check the area around the oesophagus. They will also remove some of the nearby lymph nodes. This is called a lymphadenectomy and is done because the nodes may contain cancer cells. The lymph nodes will be examined under a microscope by a pathologist. Removing them helps reduce the risk of the cancer coming back and also helps the doctors find out the stage of your cancer.
Occasionally during the operation, the surgeon discovers that the tumour can’t be removed. This may be because the tumour has spread or gone through the wall of the oesophagus, or because many lymph nodes are affected. If this happens the surgeon may insert a tube (stent) instead, to make eating and swallowing easier for you.
Some people may be able to have either part, or all, of their operation using keyhole surgery (also called minimally invasive surgery). Your surgeon can advise you on whether it’s suitable for you. In this operation, only small cuts are used rather than single larger cuts. The surgeon uses a special instrument called a thoracoscope to see and work inside the chest, and a laparoscope for inside the tummy (abdomen).
Sometimes during the procedure the surgeon decides that keyhole surgery is not suitable and will carry out standard surgery instead. Keyhole surgery should only be undertaken by experienced and specially trained surgical teams.
Having part of your oesophagus removed is a major operation. So before you have this type of surgery, your doctors will need to make sure that you’re physically able to cope with it. You will usually see an anaesthetist before your operation. Tests are carried out to check your general health and fitness, and to check your heart and lungs are working well.
If you’ve been having problems with eating and have lost weight, you may be given extra help and support with your diet to help prepare you for the operation.
Usually, you won’t have anything to eat or drink for six hours before your operation. Any chest hair will be shaved off before surgery. You may also be given special support stockings to wear. These are to help prevent blood clots developing in your legs during or after the operation.
Most people will be nursed in the intensive care or high-dependency unit for a few days after their operation.
This is routine and doesn’t mean your operation has gone badly or that there are complications. A machine called a ventilator may be used to help you to breathe for a few hours - again, this is routine in some hospitals.
The pain control has been excellent. I wouldn’t worry about pain if I had to go through it again - it’s been very good.
It’s likely that you’ll have some pain and discomfort after the operation. Your doctor or nurse will explain how your pain will be controlled. It may be controlled using an epidural, which is a fine plastic tube inserted into the space around your spinal cord so that a drug can be given to numb the nerves.
Another way to control pain is through patient-controlled analgesia (PCA). Painkilling medication is given by a pump that allows you to boost the amount if you need extra pain relief.
It’s important to let the staff caring for you know if you’re still in pain.
Mild discomfort or pain in your chest can last for several weeks, and you’ll be given some painkilling tablets to take home with you.
Drips and drains
You may have several drips and drains in place for a few days after surgery:
An intravenous (IV) drip - This is used to give you fluids until you’re able to eat and drink again.
A naso-gastric (NG) tube - This is a fine tube that passes down your nose into your stomach or small intestine and allows any fluids to be removed so that you don’t feel sick. This helps the operation site recover.
Chest drains - These are tubes that are inserted into your chest during the operation to drain away any fluid that may have collected around the lungs. The fluid drains into a bottle beside your bed. Let your doctor or nurse know if the drains are uncomfortable.
Abdominal drain - A tube may be inserted near your abdominal (tummy) wound to help drain off fluid and prevent swelling.
Urinary catheter - Sometimes a tube (catheter) is put into the bladder to drain your urine into a collecting bag. This will be removed as soon as you’re up and about.
You’ll be encouraged to get out of bed and move around as soon as possible. This helps reduce the risk of complications after surgery, such as blood clots and infections.
A physiotherapist will help you clear your lungs of any fluid that may have built up as a result of your operation. You’ll be taught deep breathing exercises to help keep your lungs clear, and taught regular leg movements to prevent blood clots forming in your legs. A physiotherapist and the ward nurses will help you with this. Your nurses will show you how to manage your drips and drains while walking.
Eating and drinking
At first you’ll only be allowed sips of liquid, until your doctor is satisfied that the join in the oesophagus is healing. You’ll usually be able to drink normally after a few days.
You may feel afraid to swallow at first, and you may have a bad taste in your mouth. Mouthwashes can help relieve the bad taste. Your surgeon may suggest a special type of x-ray to make sure the join between the oesophagus and stomach has fully healed.
Some surgeons will put a small feeding tube (a jejunostomy tube) directly into the small bowel during surgery so you can be fed through this while you’re not able to eat or drink. The tube is put into the middle part of the small bowel (the jejunum) through a small cut made in the wall of the abdomen. It’s usually removed after 4-6 weeks.
Gradually, you’ll be able to eat and drink fairly normally again. You’ll see a dietitian, who will give you support and advice. However, it’s likely that you’ll lose quite a lot of weight in the first few weeks after your operation. Try not to worry about it - the weight loss is normal and should slow down once you begin eating well. The weight loss doesn’t mean that your cancer has come back.
You may also have some diarrhoea for a while, which can usually be controlled with medicine if it continues.
Normally the stomach stores food and releases it into the bowel in a controlled way. After an operation to remove part of your oesophagus, food can travel more quickly through the digestive system. This can cause symptoms known as dumping syndrome.
There are two types: early dumping syndrome and late dumping syndrome. Late dumping syndrome is more common after an oesophagectomy.
Early dumping syndrome refers to symptoms that may happen within 30 minutes of eating a meal. You may feel dizzy, faint, and that your heart is beating faster. These symptoms may last for about 10-15 minutes. Some people also have tummy cramps and diarrhoea. The symptoms happen when food rapidly enters the bowel. This draws fluid into the bowel from the surrounding organs and tissues and causes a drop in blood pressure.
If you have symptoms of early dumping syndrome, you may be able to reduce the problem by:
eating small, frequent, dry meals
drinking fluids between meals, rather than at mealtimes
avoiding meals that are mostly made up of foods high in added sugar, such as sugary cereals
eating meals that are high in proteins (like fish, meat and eggs) and high in starchy carbohydrates (like pasta, rice, bread and potatoes)
resting for 15-30 minutes immediately after meals.
Many people find that early dumping syndrome gets better on its own in time, and that symptoms get less severe and happen less often after a few months.
Late dumping syndrome usually happens a couple of hours after meals, or when a meal has been missed. You may suddenly feel faint, sick and shaky. The problem is caused by low blood sugar levels. You can help prevent or lessen the syndrome by following the advice for reducing the symptoms of early dumping syndrome. If you feel the symptoms coming on, taking glucose tablets may help you feel better.
If your symptoms continue or are severe your doctor may prescribe a medicine to help, such as Octreotide or other similar drugs. In most people the symptoms of dumping syndrome become less severe and happen less often in time, but let your doctor or dietitian know if it continues to be a problem.
We have information about nutritional support and dietary problems after surgery.
Before you leave hospital you’ll be given an appointment to attend an outpatient clinic for your post-operative check-up. This is a good time to discuss any problems you have after your operation. But remember you can usually ring your hospital doctor, specialist nurse or ward nurse at any time if you have any problems.