Oesophago-gastrectomy (removal of part of the oesophagus and stomach)

About oesophagogastrectomy

You may need to have an oesophagogastrectomy if you have a cancer at the junction between your stomach and oesophagus. Occasionally the procedure is done as an emergency operation if you have a tear at the junction between your stomach and oesophagus.

An oesophagogastrectomy involves having the lower part of your oesophagus and the upper part of your stomach removed. The amount you have removed depends on the condition you’re getting treatment for. The remaining part of your oesophagus is then joined to the remaining part of your stomach.

Preparing for an oesophagogastrectomy

For some types of cancer, a course of chemotherapy or radiotherapy is given before surgery; this will be fully discussed with you once your diagnosis has been confirmed.

Your surgeon will explain how to prepare for your procedure. For example, if you smoke, you will be asked to stop, as smoking increases your risk of getting a chest and wound infection, which can slow your recovery.

Before you have an oesophagogastrectomy, your surgeon will need to do some tests. These are to make sure that the procedure is right for you and you’re well enough to have it. You may have the following tests.

  • Blood tests, a chest X-ray, an electrocardiogram (a test that records the rhythm and electrical activity of the heart), and sometimes an echocardiogram (an ultrasound scan of the heart) and lung function tests. These are used to check your heart and lung health.
  • Gastroscopy. This is a procedure that is used to look inside your oesophagus, your stomach and the first part of the small bowel (duodenum) using an endoscope. It allows a biopsy to be taken. A biopsy is a small sample of tissue. This will be sent to a laboratory for testing to determine the type of cells and if these are benign (not cancerous) or cancerous.
  • Barium swallow and meal. This involves swallowing a drink that contains barium (a substance which shows up on X-rays). X-ray images of the upper abdomen (tummy) then show the inside of your oesophagus and stomach more clearly.
  • CT or MRI scan. A CT scan uses X-rays to make a three-dimensional image of the body/or part of the body. An MRI scan uses magnets and radiowaves to produce images of the inside of the body. They are used to determine the size of a stomach tumour and to give an indication as to whether the cancer has spread.

An oesophagogastrectomy is performed under general anaesthesia. This means you will be asleep during the procedure. You will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand. However, it’s important to follow your surgeon’s advice.

Your surgeon will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to understand what will happen, and you can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the procedure. This will help you to be informed, so you can give your consent for the procedure to go ahead, which you may be asked to do by signing a consent form.

You may be asked to wear compression stockings to help prevent blood clots forming in the veins in your legs. You will need to have an injection of an anticlotting medicine such as heparin, tinzaparin or enoxaparin, as well as wearing compression stockings.

What happens during an oesophagogastrectomy

The procedure usually takes between three and six hours.

The operation can be performed using either open or keyhole surgery. In an open procedure, your surgeon will make a single, large cut into your upper abdomen to reach your oesophagus and stomach. In a keyhole procedure, your surgeon will make four to six small cuts in your abdomen and chest. The operation is done using special instruments, and viewed through a camera inserted into one of the cuts. Your surgeon will be able to advise which procedure is most suitable for you.

During the operation, your surgeon will remove the diseased or damaged part of your oesophagus and stomach. He or she will then rejoin the remaining part of your oesophagus to the healthy part of your stomach.

If your operation was carried out to remove cancer, your surgeon will perform a thorough examination of your stomach and the surrounding tissues to confirm the X-ray findings. Sometimes your surgeon may attach your oesophagus to your small bowel if your entire stomach needs to be removed. He or she will also remove nearby lymph nodes to check for cancer cells. This will help to find out whether you need any further treatment.

What to expect afterwards

After the surgery you might be transferred initially to the intensive care or high dependency ward. You will need pain relief to help with any discomfort as the anaesthetic wears off. You may also be offered patient controlled analgesia. This is a pump connected to a drip in your arm that allows you to control how much pain medicine you have.

If you had open surgery, you may have a catheter to drain urine from your bladder into a bag. You may also have fine tubes running out from the wound. These drain fluid into another bag and are usually removed after a day or two.

You will have a drip inserted into a vein in your hand or arm, or into the side of your neck to give you fluids. If you feel well enough, you can start to drink small amounts of water about 48 hours after your procedure.

When you wake up after the surgery, you’re likely to have a fine tube in one nostril (this is called a nasogastric tube) that goes across the area where your oesophagus and stomach have been joined. You will be encouraged to get out of bed and a physiotherapist will help you to move around. This helps prevent chest infections and blood clots in your legs. You will have daily injections to help prevent blood clots.

Two to four days after your procedure you may have a barium swallow and meal to check that the join between your oesophagus and stomach is healing properly. If the X-ray shows the join is healing well, you will be able to start drinking more water and may be allowed to have fruit juice and soup.

You will usually be able to go home two to five days after your operation. You will need to arrange for someone to drive you home. You should try to have a friend or relative stay with you for the first 24 hours.

Before you go home, you will see your surgeon who will discuss how the procedure went and any further treatment you might need. Your nurse will advise you about caring for your healing wounds and may arrange a date for a follow-up appointment.

Recovering from oesophagogastrectomy

It usually takes at least six weeks to make a full recovery from an oesophagogastrectomy, but this varies between individuals, so it’s important to follow your surgeon’s advice. If you had a keyhole procedure, your recovery will generally be faster.

If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always read the patient information that comes with your medicine and if you have any questions, ask your pharmacist for advice.

You will need to make changes to the foods you eat after your procedure and you will only be able to eat small amounts at each meal. Before you go home, you will be given specific dietary advice. To begin with, your diet will need to be very soft and pureed (a smooth cream of liquidised or crushed food). Your dietitian or surgeon will explain how to reintroduce solids into your diet. You may also be asked to take vitamin and mineral supplements.

What are the risks?

As with every procedure, there are some risks associated with oesophagogastrectomy. We have not included the chance of these happening as they are specific to you and differ for every person. Ask your surgeon to explain how these risks apply to you.

Side-effects

Side-effects are the unwanted but mostly temporary effects you may get after having the procedure, for example feeling sick as a result of the general anaesthetic.

You’re likely to have some bruising, pain and swelling in your abdomen and chest. You may also have a dry cough and diarrhoea for the first few months after the procedure.

If you had open surgery, you will have a scar, but this should fade gradually over time.

Complications

Complications are when problems occur during or after the procedure. Complications of oesophagogastrectomy can include the following.

  • Leakage. This is the most serious complication because if the join leaks, you may need further surgery.
  • Narrowing of the new join. The join may need gentle stretching to reopen it using an endoscope.
  • Heartburn (gastric reflux). As an oesophagogastrectomy involves removing the valve at the lower end of your oesophagus, you will no longer have a barrier to stop the acidic contents of your stomach pushing up into your oesophagus. When this happens, it causes a burning sensation in your chest (known as heartburn). You can help prevent this by sleeping propped up and not eating late in the evening.

Will I need to change my diet after I’ve had an oesophagogastrectomy?

Answer

Yes, you may need to adjust your diet as some foods can cause problems with your digestive system, and it may take a few months for your stomach to get back to normal. You will usually be seen by a dietitian after your procedure who will advise you about what you should or shouldn’t eat.

Explanation

For the first two or three weeks after your procedure, the food you eat should be pureed (a smooth cream of liquidised or crushed food). This is because the new join will be quite swollen and solid food won’t be able to pass through it. You may be given specific dietary advice by a dietitian.

Then, in the following few months, you will need to eat small portions often throughout the day, rather than one big meal. Small portions will be easier for your stomach to manage and will reduce your risk of heartburn (gastric reflux).

Talk to your surgeon or dietitian for more information about the foods you can eat after your procedure.

How soon can I do physical activity after I’ve had an oesophagogastrectomy?

Answer

Recovering from an oesophagogastrectomy can take some time. You will need to take things slowly for the first few weeks and build up the amount of physical activity you do gradually.

Explanation

Oesophagogastrectomy is a major operation and you will need to take it easy for a while. Immediately after the procedure you will be in bed, and on the second or third day you will be encouraged to get up and sit in a chair. Over the next few days the tubes and drips will be removed and your physiotherapist will show you some exercises to do. It’s important to do these exercises as they will help your recovery and improve your strength.

At home as you recover, you can begin to do some walking. Start by walking just around the house and then gradually increase the distance. But it’s important not to push yourself.

Around six weeks after your procedure, you should be able to start doing activities such as swimming, dancing and cycling.

Activities that involve bending down, such as gardening, may cause acid reflux. To help prevent this, you can use long-handed tools and squat or kneel instead of bending.

When can I return to work after I’ve had an oesophagogastrectomy?

Answer

The exact amount of time you will need to have off work will be specific to you. This is because it not only depends on your recovery from the procedure, but also on the condition you had treated and the type of work you do.

Explanation

The amount of time you will need to take off work will depend on a number of different factors. These can include your age, the type of work you do, how well you recover after the procedure, your general health and whether you’re having any further treatment such as chemotherapy or radiotherapy.

You’re likely to be off work for several months and you shouldn’t go back until your surgeon or doctor tells you it’s safe to do so. When you do return, you may find you get tired easily, so it’s important to take regular breaks.