Reason for Surgery

The patient has undergone an endoscopic biopsy of the upper gastrointestinal tract to confirm the diagnosis of esophageal malignancy. To seek the best chance to cure the disease and improve the quality of life of the patients, radical subtotal esophagectomy combined with mediastinal lymph node dissection is recommended, followed by esophageal reconstruction.

Physical Evaluation before Surgery

• Detailed examination revealed no evidence of metastasis in other organs except the mediastinum.
• The physiological functions of the patient's main organs, including lung, heart, liver and kidney functions, are all within the acceptable range of anesthesia and operation.
• Pulmonary function examination shows that thoracotomy and esophagectomy are acceptable for the patient's respiratory function.
• Patients with obstructed esophageal tumors have difficulty swallowing, weight loss, nutritional deficiencies, and mild anemia, which may lead to weakened immune function and increase the chance of wound infection after surgery.

Steps and Scope of Surgery

• Surgery should be performed under general anesthesia. First, the patient in left lateral position undergoes right thoracotomy for radical subtotal esophagectomy plus mediastinal lymphadenectomy. Then, the patient lies on his back and receives laparotomy to reserve the vessel innervation of the stomach or large intestine carefully. The free vessel is reconstructed into a tube, which is used as a substitute for esophageal reconstruction and is lifted up to the neck to complete anastomosis. The overall operation time is lengthy, and the patient's physical function and the care during the operation are particularly troublesome.
• After the resection, a drainage tube must be inserted into the pleural cavity for aspiration to facilitate the discharge of excess thin blood and prevent empyema.
• In reconstructive surgery, the stomach is preferred as an alternative to the esophagus, on the grounds that the operation only requires cervical anastomosis, followed by the large intestine, in which the operation time is slightly longer and the anastomosis needs 3 joints.
• A Jejunostomy tube is usually placed for patients during operation, which can be used for short-term milk feeding and nutritional supplement after operation.

Expected Surgery Success Rates and Risks

• According to literature records and recent reports, although surgical resection of esophageal cancer is a major surgery, the risk before and after surgery has been greatly reduced due to the improvement of anesthesia technology and postoperative intensive care. Excluding concomitant underlying systemic diseases such as hypertension, diabetes, coronary artery disease, or other organ failure, the mortality rate after surgical resection of esophageal cancer is generally between 5% and 10%.
• In general, the treatment effect of patients with esophageal cancer is better when the tumor can be completely removed. The five-year survival rate after surgery is related to the early and late stages of the disease. However, patients clinically diagnosed with esophageal cancer due to dysphagia usually fall into the second or third stage. The five-year survival rate after surgery is about 30% and 15% respectively, if Stage II and III esophageal cancer is confirmed after the operation.

Possible Symptoms Expected after Surgery

• After surgery, depending on the patient's recovery, he/she is usually transferred to the intensive care unit to facilitate the smooth recovery of respiratory function.
• After the operation, the patients will be temporarily put on respirators in intensive care units to help them recover smoothly after the long procedure and prevent comorbidities such as sputum obstruction, fever and pneumonia caused by lung collapse. During which, they are not fit to speak for the time being and must receive treatment at ease.
• Since patients need to be closely monitored in the intensive care unit for at least a few days after surgery, in order to avoid their emotional anxiety, insomnia, fear and other adverse conditions, we sometimes consider giving patients sleep therapy.
• Postoperative respiratory rehabilitation, nutritional adjustment and wound care are important. In addition to proper pain control, steam inhalation to reduce phlegm, repeated slapping of the back to remove phlegm, and continuous deep breathing exercises, the cooperation from patients, family members and all medical staff is the best guarantee for smooth postoperative recovery.

Possible Complications, Risks and Management

• Very few patients may be allergic to anesthetic agents and may be at risk of skin rash, hypotension, tracheal constriction, or even severe shock.
• Respiratory rehabilitation after the operation is very important, especially for heavy smokers, the elderly with emphysema, those with poor nutrition and difficulty breathing, and those who suffer from sputum obstruction due to intolerable wound pain. As a result, they may need to receive ventilator support treatment in the intensive care unit due to insufficient alveolar ventilation leading to lung collapse, bronchial obstruction, fever, pneumonia and even respiratory failure.
• The pleural space after thoracotomy may have accumulation of blood or exudate leading to hemothorax or empyema.
• Most patients may require blood transfusion because of poor nutrition, weight loss or anemia before surgery.
• Very few patients are reported to have a stroke, heart failure, pulmonary water or myocardial infarction during general anesthesia surgery due to older age, or vascular sclerosis, arrhythmia.
• Complications such as wound infection, anastomotic leakage, aspiration pneumonia, intra-abdominal abscess, upper gastrointestinal bleeding, and sepsis may occur in the patients with different health conditions and operations received.
• The incidence of comorbidities after surgery is about 30%, and the mortality is about 5-10%.

Possible Consequences if Surgery is not Performed

• Esophageal cancer is a highly malignant tumor, prone to esophageal obstruction, bleeding, trachea fistula or distal metastasis. If, after careful pre-operative evaluation, the tumor remains confined to the esophageal tissue, with no distal metastasis or invasion of vital organs in the chest, surgical resection and reconstruction is recommended as soon as possible to maintain the quality of life of oral feeding and avoid comorbidities of respiratory infection.
• When esophageal cancer is associated with distal metastasis, the possible clinical discomfort varies with the organs involved, including pain from skeletal metastasis, liver failure and swelling from liver metastasis, pulmonary interstitial edema from lymphatic metastasis, pleural effusion or respiratory failure after lung metastasis, conscious state of brain metastasis or limb paralysis similar to cerebral apoplexy, and so on.
• Complete obstruction of the esophagus by tumor can cause bad constitution, poor resistance, inhalation lung cancer, bleeding, pain, fever, dyspnea and so on.

Alternatives to Surgery

Under the medical considerations of oncology, if the patient decides not to undergo surgical resection, or if the physical function and tumor condition are no longer suitable for surgical treatment, it is advised to choose chemotherapy, cobalt 60 therapy or combination of the above according to the individual condition of the patient.

According to the present statistics, the five-year survival rate for tumors less than 5cm with cobalt 60 radiation treatment is about 10% ~ 20%. And the efficacy of chemical therapy is not ideal, with only about 15 to 20 percent of the tumor shrinkage response rate.