The esophagus is a very simple organ that starts at the posterior pharynx (back of the throat) and ends in the stomach. Its main purpose is to transport food from the mouth to the stomach. It is approximately 10 to 12 inches long and propels the food by alternate contraction and relaxation of muscles that line the esophagus. Its propelling power is quite weak, so this passage is aided by gravity; however, it does allow for food to be carried to the stomach even when lying down. The main reason the esophagus is 10 to 12 inches long is because the stomach is in the abdomen. If the stomach were up in the chest it would be shorter. To connect the mouth to the stomach, the esophagus needs to pass through the diaphragm, a muscle that extends across the body and divides the chest from the abdomen.

Another function of the esophagus is to prevent acid from flowing back into it. This is accomplished by a one or two inch portion of the esophagus which resides within the abdominal cavity. The abdominal cavity has a higher pressure than the chest cavity; therefore gastric contents have a tendency to flow back into the esophagus. This is prevented by the esophageal sphincter, which is a portion of the esophagus in the abdominal cavity, which therefore collapses with the high pressure.

Cancer of the esophagus is an unusual malignancy, not only because the incidence varies widely in different countries, but also because the cause is different in different geographical areas. For instance, in the U.S. among Caucasians there are 5 esophageal cancers per 100,000 people, whereas in Linxia in China the incidence is 500 per 100,000 people. Heavy alcohol drinking and smoking are causes of esophageal cancer in the U.S. and in areas of Europe such as France. However, in the Orient esophageal cancer is found to be related to diet, particularly smoked and pickled foods. It is interesting that in domesticated animals such as chickens, that eat the scraps of their keepers, the incidence of cancer is also very high in China. In Africa, the cause of cancer is more likely to be related to fungi.

However, over the past 15 to 20 years a different type of cancer is rapidly developing in America. This is a cancer of the portion of the esophagus that adjoins the stomach and is related to acid reflux. Acid reflux causes injury to the esophagus; the esophagus, in order to protect itself, produces a lining, which is very similar to that of the stomach or the colon. This condition is called Barrett’s esophagus. Ten percent of these individuals eventually develop cancer. This cancer has the highest increase rate in the U.S. at this time.

The diagnosis is usually made by a barium swallow, which is an x-ray of the esophagus done while the radiologist watches under x-ray while the patient is swallowing. This will show if there is a narrowing of the esophagus, and if this is the case the next step is to have an esophago-gastroscopy or upper endoscopy (a flexible tube through which one can see the esophagus). A biopsy of suspicious areas is done. If the biopsy is positive for cancer, it is followed by a CT scan to evaluate the extent of the tumor and if metastasis to the lymph nodes or the liver are present. Other tests such as endoscopic trans-esophageal ultrasound are sometimes helpful to demonstrate thickening of the esophagus and whether lymph nodes are enlarged, and this is slightly more accurate than a CT scan in this case. This test may also be used to determine whether or not to use chemotherapy and radiation before surgical removal of the esophagus.

In general, in a patient who is in good health and does not have spread of cancer (metastasis), the treatment for cancer of the esophagus is surgery. Some or most of the esophagus is removed.

Patients are astounded that most of the esophagus is removed. One has to remember that the function of the esophagus is to carry food to the stomach. It makes little difference whether it is 2 inches or 12 inches in length.

In general there are three approaches to removal of cancer of the esophagus:

1) The Ivor Lewis approach:

With this technique, the surgeon makes an incision in the abdominal cavity and detaches the stomach from its attachments to the spleen and colon. Then the abdomen is closed and the surgeon opens the right chest, through the ribs, and takes the esophagus out. He then brings the stomach into the chest and connects the stomach up to the esophagus approximately 4 inches from the neck within the chest.

This approach has advantages in that one can see very clearly the whole esophagus, and for this reason this approach had been the classical approach into the 1980s. The dissection is done under direct visualization and lymph nodes can be removed for sampling. The anastomosis (both ends are brought together) is made in the chest. The disadvantage is that one has to open the chest and there may be more pain and discomfort, and perhaps more instances of pneumonia. If there should be a rupture of the suture line, saliva and food enters the chest, the patient becomes quite ill, and may die. No attempt is made to take out all the lymph nodes of the chest.

2) Blunt esophagectomy, or transhiatal esophagectomy:

This procedure has been used in the last 20 to 25 years. The abdomen is opened as in the Ivor Lewis approach, and the stomach is prepared. However, instead of going through the right chest and the ribs, the surgeon will go through the diaphragm without another chest incision, and with the hand he will take out the esophagus all the way up into the neck. Then another small incision is made in the neck, the esophagus is brought out at this point, and the stomach is brought up to the neck, 2 inches higher than that of the Ivor Lewis technique. The connection of the esophagus to the stomach is made up in the neck.

The advantages of this procedure are that there is only one large incision in the abdomen, no chest incision, less incidences of pulmonary complications, and if there should be a leak up in the neck, there is no serious consequence with infection in the chest. The disadvantage is that not many nodes are taken. This operation is based on the premise that when the lymph nodes have cancer the survival of the patient is not increased by taking out more lymph nodes.

3) Radical esophagectomy:

This is performed the same as the Ivor Lewis procedure, but as many of the lymph nodes as possible are taken out. This is based on the theory that the more lymph nodes taken out the better the chance for a cure. This seems to have some promise as demonstrated in the far Eastern experience, but in the U.S. it does not have many proponents. When radical esophagectomy was performed in the U.S., the mortality increased and the cure rate was not improved. More recently, a few surgeons have demonstrated some improvement in the mortality and the survival of these patients. This operation takes 6 to 8 hours and can only be performed in very fit patients.

In general, we perform transhiatal esophagectomies with a mortality rate of less than 4% and a 5-year cure rate of 18 to 20%. The cure rate is no higher in the Ivor Lewis approach, and the postoperative mortality is often higher. The radical esophagectomy may produce more cures but the mortality is higher, so more experience is needed to prove this point.

If I have surgery for cancer of the esophagus, will I need chemotherapy or radiation therapy?

The next question that arises is whether the patient should have chemotherapy prior to surgery. Many reports have been written, but there is no strong evidence that chemotherapy either before surgery or after surgery is statistically very helpful. However, we do know that when patients have a very good response to chemotherapy prior to surgery, the survival is much better. We actually have patients who had far advanced cancer and who have been cured by the combination of surgery and chemo-radiation. We do suggest preoperative chemotherapy in patients who are in good health and robust, and who have a cancer that is gone beyond the muscle wall of the esophagus.

When a CT scan does not show a bulky tumor we perform a preoperative transesophageal ultrasound to determine the extent of the tumor. If the tumor has extended through the esophagus, we recommend preoperative chemotherapy and/or radiation.

The downside of chemotherapy is that it has risks in and of itself, and is associated with increased complications after surgery.

In patients who do not have extensive disease, a decision is not made about the need for chemotherapy or radiation therapy until after surgery and the exact extent of the cancer is known. It is not recommended for everyone, and depends on the patient’s physiologic strength. It is likely that this will be discussed with an oncologist (a doctor who specializes in non-surgical treatment of cancer).

When surgery is not recommended for cancer of the esophagus, in most cases radiation therapy, chemotherapy, or a combination of these is recommended. In advanced cases a tube is placed in the esophagus through the tumor so the patient can swallow.

Usually, a patient is in the intensive care unit for 2 to 3 days. They can expect to be on a respirator for at least 24 hours, and if they do well the respirator will be removed after 24 hours. Many patients with esophageal cancer have deteriorated lung function, and therefore they may have to be on the respirator longer. They will have a tube from the nose into the stomach (which is now in the chest) for four days, and when this is removed the patient is allowed to have clear liquids and gradually a more advanced diet. The usual hospital stay is 8 to 12 days.

Some of the complications of this surgery are hoarse voice, transient difficulty with swallowing, and change in eating habits. This operation has the same result on eating as an ulcer operation. Patients may not be able to eat as much at one time, they may get full more easily, and after they eat they may have some cramps and diarrhea. Very few of these symptoms last more than 3 to 6 months and they slowly get better.

Who can do this kind of surgery? Where do I find a doctor?

Operations on the esophagus are not very common. It is important to have a surgeon who has experience in these operations, and that does this kind of surgery on a regular basis. Most of the time patients will need to go to a teaching hospital to find surgeons with this kind of experience, and to find a hospital that is experienced and equipped to do these procedures. The surgeon should always be asked how many times he has done the same procedure he is planning to do, and what his survival rate is. The patient should always do his homework and ask about the surgeon from others. The patient should not be afraid to get more opinions. Convenience to the patient’s home is not the important thing in this case, experience is. Our experience is that 96% of our patients survive the surgery and go home, which is among the best in the country.