Oesophageal cancer

Cancer cells can also detach from the primary tumour and migrate to the lymph nodes or other organs (liver, lungs, bones), where they form new tumours called metastases. The main risk factors for oesophageal cancer are smoking, alcohol consumption and their combination, as well as gastro-oesophageal reflux (Barrett’s oesophagus). In Belgium, 1,400 new cases are recorded each year. It is four times more common in men than in women. Surgical treatment for oesophageal cancer is offered depending on the stage of the tumour.

To determine this stage, a series of diagnostic examinations will be performed:

• An endoscopy of the oesophagus and stomach, during which biopsies of the tumour will be taken and sent for analysis
• A cervicothoracoabdominal CT scan to assess the extent of the disease
• A PET scan to assess the extent of the disease
• Endoscopic ultrasound to assess the depth of the tumour and the presence of lymph nodes (with a biopsy needle aspiration if necessary)
• A nutritional assessment
• A cardiorespiratory assessment
• A geriatric oncology assessment if you are over 70 years old

Depending on your needs, other examinations may be performed (MRI, bronchoscopy, ENT consultation, etc.). The diagnosis of cancer is confirmed by the histopathological analysis of the biopsies taken. There are two types of cancer originating in the mucosal layer of the oesophagus: squamous cell carcinoma and adenocarcinoma.

Which surgery?

These various examinations make it possible to offer treatment tailored to your situation, depending on the type of cancer, the extent of the disease and your general condition. The choice of treatment is made after analysing the various results, which will be discussed at a multidisciplinary meeting attended by surgeons, oncologists, radiologists, gastroenterologists, radiotherapists, pathologists and other relevant specialists. Surgery is the treatment offered for localised cancers. It involves removing all or part of the oesophagus. Reconstructive surgery using the stomach or intestine (small intestine or colon) is performed at the same time to restore continuity of the digestive tract. The lymph nodes near the tumour, oesophagus and stomach will also be removed and sent for histopathological analysis. Surgery may be preceded by chemotherapy, combined in some cases with radiotherapy, depending on the extent of the disease.

If the tumour cannot be operated on, chemotherapy may be offered, with or without radiotherapy. This treatment aims to slow the progression of the disease, relieve symptoms and improve quality of life. Depending on the location and type of tumour, the surgeon will use two or three surgical approaches:

• Abdominal and right thoracic approach (subtotal oesophagectomy)
• Abdominal, right thoracic and left cervical approach (total oesophagectomy)

Before your surgery

Good preparation for surgery is essential. You will therefore be asked to follow a series of recommendations:

• Stop smoking: this will reduce the risk of pulmonary complications after your surgery.

You are advised to stop smoking 4 to 6 weeks before your procedure. A tobacco specialist at our hospital can help you do so.

• Avoid alcohol: alcohol can interact with the medicines we will need to give you. You are advised to stop drinking alcohol at least 4 weeks before your procedure. Psychological support may be offered to help you do so.
• Walking: exercising daily (brisk walking for up to 30 minutes twice a day) will prepare you to be in better condition for your procedure.
• Breathing exercises: you will be given a small spirometer to carry out your exercises at home and prepare your lungs as well as possible for the procedure.
• Low-fibre diet: to be started 5 days before your procedure (you will be given a list of permitted foods during your appointment with the surgical coordinator).

Our surgical coordinator will also arrange appointments for you with an anaesthetist, a dietitian and a physiotherapist to prepare you as well as possible for your procedure. If you have lost a lot of weight, a dietitian will prescribe nutritional supplements. Before your procedure, maintaining your healthy weight and muscle mass is a priority in order to prevent malnutrition. Malnutrition is a condition resulting from an insufficient nutritional intake compared with your energy and protein requirements. You must eat enough healthy, varied and balanced food to maintain your strength, immunity and resistance to infections, and thus avoid certain complications during your surgery. We therefore recommend a nutritional supplement that supports immunity and wound healing through arginine, omega-3 fatty acids and nucleotides. You may also consume the same supplement in the event of malnutrition after your surgery. Sometimes, it will be necessary to place a nasogastric feeding tube, a gastrostomy or a jejunostomy endoscopically or surgically to provide nutrition.

You will be admitted to hospital 24 to 48 hours before your surgery. On the day before your procedure, you will be asked to drink apple juice (approximately four 20 cl cartons) or non-carbonated iced tea (approximately three 33 cl cans). From midnight onwards, you must no longer eat solid food; you may continue to drink clear liquids (liquids containing no pulp or milk) until 4 hours before your anaesthetic. The anaesthetist or your surgeon will prescribe the medicines you may take on the morning of the procedure with a sip of water.

After your surgery

After the procedure, you will remain under observation overnight in a post-anaesthesia care unit before returning to your room the following morning. In some situations, monitoring in the intensive care unit will be necessary. To reduce postoperative pain, the anaesthetist will have placed an epidural before the procedure, which will continuously deliver painkillers. You will keep it for 5 days. You will also receive intravenous painkillers. You will be asked to assess your pain daily on a scale from 0 to 10: a score below 4 out of 10 indicates that your pain is well controlled.

Drains are also placed during the procedure (in the thoracic and abdominal and/or cervical areas) to remove accumulated fluid. They will be removed progressively during your hospital stay. A urinary catheter, a small tube inserted through your urinary canal into your bladder to allow urine to drain, is placed during the procedure and will be removed within 48 hours after the operation unless contraindicated. A nasogastric tube, placed during the procedure through the nose and down the throat into the stomach, is left in place to empty the contents of your stomach during the first few postoperative days. It will be removed after the follow-up radiographic examination (OED).

After your procedure, you will remain strictly nil by mouth until the OED has been performed. You will then receive nutrition either parenterally (through a venous system), through a jejunostomy tube (a small tube placed in the small intestine during the procedure), or through the nasogastric tube. Intensive respiratory physiotherapy and mobilisation sessions will be prescribed daily and started the day after the procedure. The follow-up radiological examination will be performed between the 6th and 7th postoperative days. If the examination shows no leak at the anastomosis (the suture between the oesophagus and stomach), the nasogastric tube will be removed and you will be allowed to drink, but only a few sips of water. Oral feeding will then be resumed. You will be given instructions for a soft, puréed and small, frequent-meal diet for 6 to 8 weeks.

Your eating habits will also need to be adapted after surgery

Initially, the texture of your food will be modified. It should be puréed or soft, that is, easy to eat, for example: bread without crusts, soaked rusks, dairy products, minced meat (e.g. minced steak, prepared steak tartare, meatloaf, etc.), tender poultry (e.g. chicken thigh, etc.), boneless fish, eggs, mashed potatoes, cooked, tender and low-fibre vegetables (e.g. cooked carrots, courgettes, etc.), stewed fruit or very ripe fruit without the skin (e.g. kiwi, pear, etc.), and so on.

Later, the diet can be broadened, but thorough chewing will be important because your jaw will act as a blender. You should eat in a calm, stress-free environment, dividing your food intake into smaller meals (6 small meals spread throughout the day), because the procedure reduces the portion sizes you can eat. You should also drink between meals in small sips (1 to 1.5 litres per day), avoiding carbonated drinks, especially during the first month. Do not hesitate to enrich your diet, as your food portions will be smaller. For example, add an egg yolk to mashed potatoes, meatballs or melted cheese to soup, or crème fraîche to vegetables.

Risks and complications associated with the procedure

1. During the procedure:

• Bleeding that may require a blood transfusion
• Rib fracture related to the right thoracotomy, which will be treated with painkillers.

2. After the procedure:

• Pulmonary and infectious complications.
• Anastomotic fistula: this is a leak at the suture site between the oesophagus and stomach. Initially, it will be treated medically, with possible drainage or placement of a prosthesis endoscopically. Very rarely, repeat surgery is indicated.
• Delayed gastric emptying, with or without pyloric spasm. This will be treated medically (with medication to stimulate gastric emptying), possibly combined with an endoscopic procedure on the pylorus.
• Wound infection treated with local care, possibly combined with antibiotics.
• Long-term stenosis of the oesophagogastric anastomosis: this is a narrowing at the suture site between the oesophagus and stomach, revealed by difficulty passing food. Treatment is endoscopic dilatation or placement of a prosthesis.
• Long-term gastro-oesophageal reflux, treated with postural measures and medication.

Returning home

You may return home after 9 to 12 days in hospital. You will be given a prescription for nursing care for wound care. To prevent thrombosis, you will receive a daily subcutaneous injection of an anticoagulant until the thirtieth postoperative day. Your prescription for painkillers will also be adjusted. It is important to continue your exercises at home (spirometer, walking, etc.).

You will see your surgeon, dietitian and physiotherapist again approximately one month after your surgery.