54 - Oesophagectomy

Summary

Introduction

Surgical pathology of the oesophagus is dominated by cancer; squamous carcinoma and adenocarcinoma are the most common types. The incidence of squamous carcinoma is affected by environmental factors, such as smoking and alcohol consumption. On the other hand, adenocarcinoma is mostly associated with gastro-oesophageal reflux (Barrett's disease) and comprises 50% to 70% of cases in the developed world.

Other oesophageal disease requiring surgical correction and perhaps postoperative critical care includes surgery for motility disorders (achala-sia), gastro-oesophageal sphincter pathology, ingestion of caustic or foreign bodies and various other disorders (e.g., Plummer–Vinson, Mallory–Weiss).

Oesophageal surgery leads to significant morbidity and mortality, contributed to by the prolonged and complex surgery itself and the often poor preoperative condition of the patients. Respiratory complications are the most common, and provision of good analgesia is always essential.

Conduct of surgery

The surgical technique chosen determines whether critical care admission is required (which is common) and significantly influences outcome and length of stay. The resection can be limited to the tumour itself (standard oesophagectomy) or may be extended to include lymphadenectomy (radical oesophagectomy). Although it is considered that survival depends on the completeness of the resection, what constitutes an adequate resection margin is still debated. The operative approach may include thoracotomy, laparotomy and/or a cervicotomy (neck incision), according to the location of the tumour and the technique chosen by the surgeon.