Oesophagectomy Treatment

Open surgery versus minimally invasive surgery

Traditionally, oesophagectomy was performed as open surgery, which involves making a large incision in the chest, the abdomen or both to gain direct access to the oesophagus. This method remains valid and necessary in certain cases, as it gives the surgeon a complete, direct view of the surgical area4.

In recent years, many surgeons have adopted minimally invasive techniques to perform this operation. Laparoscopic surgery allows access to the abdominal organs through several small incisions of approximately 2–3 centimetres instead of a single large cut. The surgeon inserts special instruments and a tiny camera that projects magnified images onto a screen. Similarly, thoracoscopic surgery uses the same principle to access the organs in the chest4.

Minimally invasive techniques offer several potential advantages for patients. Smaller incisions usually cause less pain after the operation, reduce the risk of wound infection and allow a quicker recovery. However, not all patients are suitable for this type of surgery, and in some cases the operation has to be converted to open surgery if complications arise during the procedure3.

Main oesophagectomy techniques

An Ivor Lewis oesophagectomy is one of the most common techniques. In this procedure, the surgeon makes two incisions: one in the abdomen and one on the right side of the chest. Through these incisions, the oesophageal tumour is removed and a new connection is created between the stomach and the remaining part of the oesophagus in the upper chest. This technique is particularly useful when the tumour is located in the middle or lower part of the oesophagus5.

An transhiatal oesophagectomy is another option that uses incisions in the neck and abdomen but avoids opening the chest. The surgeon removes the oesophagus from these two locations, which may reduce some of the complications associated with chest surgery. However, this technique provides a more limited view of the surgical field4.

An three-incision oesophagectomy combines approaches through the neck, chest and abdomen. Although it is more extensive, it allows better visualisation and may be necessary for tumours located in the upper part of the oesophagus or when a wider resection is required4.

Endoscopic surgery for very early cancer

When cancer is detected at a very early stage, limited to the most superficial layers of the inner lining of the oesophagus, a much less invasive procedure may be possible. Endoscopic surgery allows the doctor to remove abnormal cells or early cancer without having to remove the whole organ. This procedure is performed by passing a flexible tube with a camera and special tools through the patient’s mouth into the oesophagus6.

This technique is only suitable for a very carefully selected group of patients with early-stage disease. The main benefit is that it avoids major surgery, preserves the entire oesophagus and allows a much faster recovery. However, it requires very close follow-up to make sure the cancer does not come back6.

Combined treatments: chemotherapy and radiotherapy

In many cases, especially when oesophageal cancer is at a more advanced stage, surgery alone is not enough. Doctors often recommend combining oesophagectomy with other treatments to improve the chances of success. Neoadjuvant chemotherapy involves giving anti-cancer medicines before surgery, with the aim of shrinking the tumour and making it easier to remove completely2.

An radiotherapy, which uses high-energy rays to destroy cancer cells, can also be given before the operation, often in combination with chemotherapy. This approach, known as chemoradiotherapy, has been shown to improve outcomes in patients with certain types and stages of oesophageal cancer. In some cases, when surgery is not possible because of the location of the tumour or the patient’s state of health, chemoradiotherapy can be used as the main treatment2.

The most commonly used chemotherapy medicines include combinations of several drugs that act in different ways to attack cancer cells. These treatments have significant side effects, such as nausea, loss of appetite, extreme fatigue, hair loss and weakened immune defences, which increases the risk of infection. Doctors monitor patients closely during treatment and adjust doses as needed2.

Duration of treatment and recovery

The total duration of treatment varies considerably depending on the approach chosen. When chemotherapy or chemoradiotherapy is given before surgery, this period can last between six and twelve weeks. After completing this initial treatment, doctors wait a few weeks before performing the oesophagectomy, to allow the patient to partially recover and to assess how the tumour has responded2.

The hospital stay after an oesophagectomy usually lasts between one and three weeks, depending on whether complications arise. The first few days after surgery are critical, and many patients spend this time in an intensive care unit where they can be monitored continuously. Full recovery at home can take several months, during which the patient must gradually adapt to significant changes in the way they eat1.

Anastomotic leak

The most serious and feared complication is anastomotic leak, which occurs when the surgically created connection between the remaining oesophagus and the stomach does not heal properly and develops a leak. This allows digestive contents to escape into the chest or abdomen, causing serious infections that can be life-threatening. Anastomotic leaks occur in approximately 10–20% of cases, although rates vary depending on the surgical technique used and the experience of the centre7.

Detecting an anastomotic leak early is crucial to improving the outlook. Warning signs include persistent fever, chest pain, difficulty breathing, a raised heart rate and abnormal-looking fluid in the surgical drains. When a leak is suspected, doctors carry out special imaging tests with contrast to confirm the diagnosis7.

The treatment of an anastomotic leak depends on its severity. In mild cases, it may be enough to stop eating and drinking by mouth and provide intravenous nutrition, allowing the leak to heal on its own. However, more serious leaks require further interventions, which may include placing drains to remove the infected fluid, endoscopic procedures to seal the leak with clips or special stents, or even another operation in extreme cases7.

Lung complications

Breathing problems are extremely common after an oesophagectomy. The surgery affects the patient’s ability to breathe deeply and cough effectively because of pain and the handling of tissues close to the lungs. This encourages secretions to build up in the lungs, increasing the risk of pneumonia (lung infection) and atelectasis (partial collapse of the lung)7.

To prevent these complications, medical teams carry out intensive programmes of respiratory physiotherapy from the first day after surgery. This includes deep breathing exercises, the use of special devices to expand the lungs and getting the patient moving early. Despite these preventive measures, approximately 20–30% of patients develop some kind of lung complication7.

Other important complications

A chylothorax is a complication that occurs when the thoracic duct, a major lymphatic vessel that carries a milky, fat-rich fluid, is injured. This causes the fluid to build up in the space around the lungs. Although it is less common than other complications, it can be difficult to manage and often requires strict dietary changes or additional procedures7.

Heart problems, especially arrhythmias (abnormal heart rhythms), may appear in the days following surgery. Atrial fibrillation is the most common arrhythmia and may require treatment with medicines to control the heart rhythm. Surgical wound infections, although less serious than leaks or pneumonia, can also occur and require treatment with antibiotics and sometimes surgical drainage7.

Phases of clinical trials

Clinical trials are carried out in progressive stages, each designed to answer specific questions. Phase I trials are the first studies in humans and focus mainly on assessing the safety of the new treatment. Researchers determine the right dose and identify side effects. These studies usually include a small number of patients who have not responded to standard treatments2.

The Phase II trials assess whether the treatment actually works against the cancer. Researchers monitor whether tumours shrink or stop growing and continue to keep a close eye on safety. If a treatment shows promising results in Phase II, it moves on to larger studies2.

The Phase III trials are large-scale studies that compare the new treatment with the current standard treatment. They involve hundreds or thousands of patients, and the results of these studies determine whether a new treatment will be approved for widespread use. Patients are usually assigned at random to receive either the new or the standard treatment, a process called randomisation2.

Immunotherapy for oesophageal cancer

One of the most promising advances in the treatment of oesophageal cancer is immunotherapy, which uses the patient’s own immune system to fight the cancer. Unlike traditional chemotherapy, which attacks cancer cells directly, immunotherapy “teaches” the immune system to recognise and destroy tumour cells2.

The immune checkpoint inhibitors are a type of immunotherapy that has shown encouraging results. These medicines block specific proteins that cancer cells use to “hide” from the immune system. When these proteins are blocked, immune cells can detect and attack the tumour more effectively2.

Several studies are investigating these medicines both on their own and in combination with chemotherapy. Some of these treatments have been shown to prolong survival in patients with advanced oesophageal cancer that cannot be operated on. The side effects of immunotherapy differ from those of chemotherapy and may include immune system reactions that affect healthy organs, such as the bowel, the lungs or the endocrine glands2.

Molecularly targeted therapies

The targeted therapies are treatments that attack specific molecular features of cancer cells. Researchers have found that some oesophageal cancers have changes in particular genes or proteins that drive tumour growth. Targeted medicines are designed to block these specific pathways2.

For example, some oesophageal adenocarcinomas produce excessive amounts of a protein called HER2. Medicines that specifically block this protein have been shown to improve outcomes when combined with chemotherapy in patients whose tumours have high levels of HER2. Before considering this treatment, doctors must carry out special tests on a tumour sample to determine whether the patient is suitable2.

Experimental surgical techniques

Surgeons continue to refine oesophagectomy techniques to improve outcomes and reduce complications. Robotic surgery is an evolution of minimally invasive surgery in which the surgeon controls robotic arms that provide greater precision and flexibility than conventional laparoscopic instruments. Current studies are assessing whether this technology translates into better outcomes for patients3.

Some centres are investigating enhanced recovery after surgery protocols, which include specific strategies to minimise surgical stress and speed up recovery. These programmes include nutritional optimisation before surgery, special anaesthetic techniques, very early mobilisation of the patient and innovative pain management. Preliminary results suggest that these protocols can reduce complications and shorten hospital stays8.

Location of clinical trials

Clinical trials for oesophageal cancer are carried out in specialist medical centres around the world. In the United States, many studies are available at leading cancer centres. In Europe, several countries, including the United Kingdom, Germany, France and Spain, are actively involved in clinical research on this disease. The availability of specific trials varies over time, and each study has its own eligibility criteria relating to the stage of the cancer, previous treatments received and the patient’s general health2.