An oesophagectomy is the name for the very major operation that is normally performed for oesophageal cancer with the aim of curing it or for high-grade dysplasia with the intention of preventing cancer development. The oesophagus is a long muscular tube that runs from the back of the mouth in the neck, through the entire length of the chest, and into the abdomen. Thus in order to successfully remove the oesophagus, access into the chest, abdomen and neck may be required. There are a variety of methods described for oesophagectomy, all of which involve at least two, sometimes three large incisions in the abdomen, chest and neck. Abdominal incisions have to be very large to enable access to the stomach and reach the lower part of the oesophagus is in an area very difficult to access. Retractors have to be used to forcibly keep open the abdomen during surgery. Chest incisions are even more demanding, with a very large cut being made in a space between the ribs. In order to get to the oesophagus, which lies at the very back of the chest, the chest has to be expanded, and this may require the removal of a rib, and fractures of others. Once the oesophagus and surrounding tissues (containing lymph nodes) have been removed, a new oesophagus is created using the normal lower part of the stomach.

The operations carried out today have until recently, differed very to those described fifty to a hundred years ago. The large incisions not only cause severe pain, they result in a greater risk of complications including chest infections, and requirements for blood transfusion that makes recovery from this operation exceedingly difficult. It may take many months to return back to a quality of life comparable to before the surgery.

There is a huge potential benefit of this kind of surgery being performed using keyhole surgery. Avoiding large chest or abdominal incision will dramatically reduce blood loss, risk of infection and post-operative pain. As a result, recovery and return to a normal quality of life is much more rapid.

Attempts to perform this keyhole surgery oesophagectomy in the early 1990’s when this technology was relatively new failed to be successful. However, over the last five years, the combination of greater surgical experience and improvement on all aspects of keyhole surgery technology has meant that oesophagectomy can be performed safely and successfully by keyhole surgery.

This operation, known as minimally invasive oesophagectomy (MIE), was pioneered by Professor Jim Luketich MD, from the University of Pittsburgh, USA. His method (now performed in several hundred patients) is the one that we have adopted in Exeter, and currently to our knowledge; we are the only Upper GI cancer centre in the United Kingdom to offer this service.

The first stage of the operation is known as thorascopic mobilisation. A number of small cuts (1com or 0.5 cm, usually four in total) are made on the right side of the chest to enable the entry of an operating telescope and the instruments, The lung is temporarily collapsed, and the entire length of the oesophagus from the neck to the abdomen is dissected using the special keyhole instruments. Tissue surrounding the oesophagus containing lymph nodes is also dissected and can be removed at this stage. After this has been completed similar small cuts are made into the abdomen to allow gastric mobilisation. The stomach is freed from the structures around it using special keyhole surgery instruments. One major blood vessel is carefully preserved to keep the stomach alive, the rest are dissected away. Once the stomach has been mobilised in this manner, it is carefully resected using endoscopic stapling devices (cut tissue and seal the cut ends with staples). The resection is carried out in a very specific way such as the lower (greater curve) normal part of the stomach is fashioned to form a tube, while the upper part of the stomach and disease oesophagus is isolated. Finally a small incision is made in the neck, and the oesophagus identified here. Since the oesophagus is now completely free throughout its length, it is simply pulled up into the neck, bringing with it the gastric tube. The oesophagus is then divided to remove virtually all but a small segment in the neck, and this is joined to the gastric tube, making a new oesophagus.

The entire operation can take between 8 to 10 hours. In Exeter, Mr. Saj Wajed, Consultant Upper GI surgeon and Mr. Richard Berrisford, Consultant Thoracic surgeon work together as a team on all patients who require this surgery.

So far our experience has been very encouraging, and we offer this to all patients who would normally have had traditional oesophagectomy. Patients do not require admission to an intensive care unit bed, and are home between 7 to 10 days after the operation. Return back to normal quality of life seems to be much quicker, and we are currently collecting our data to support these statements.

Keyhole surgical techniques may be applicable to certain tumours of the stomach, particularly if they are of a more benign nature (eg GIST’s), the location is favourable and the disease is at an early stage. As with MIE, the operation has to be carried out in an identical manner to that of an open operation, but using much smaller incisions. Gastric cancer operations rarely involve opening the chest, so the small keyhole skin incisions only involve the abdomen. Gastric mobilisation and resection are carried out with the operating telescope and special instrumentation. A slightly larger incision may be required in order to remove the diseased stomach through the abdomen, but the location of this can be both cosmetic and less likely to cause pain and discomfort. Recovery therefore is much more rapid and complication free.