Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (ie, McKeown esophagectomy or tri-incisional esophagectomy)
CPT4 code
Name of the Procedure:
Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (i.e., McKeown esophagectomy or tri-incisional esophagectomy).
Summary
A total or near total esophagectomy is a surgical procedure to remove most or all of the esophagus, the tube that carries food from the mouth to the stomach. It involves making incisions in the chest, neck, and abdomen to remove the esophagus and reconnect the digestive tract, often using the stomach. This is known as the McKeown esophagectomy or tri-incisional esophagectomy.
Purpose
The procedure is primarily used to treat esophageal cancer and severe esophageal damage. The goal is to remove diseased tissue and restore the ability to swallow by reconstructing the digestive tract.
Indications
- Esophageal cancer
- Severe esophageal strictures
- Barrett’s esophagus with high-grade dysplasia
- Non-responsive to other treatments
Preparation
- Patients may need to fast for a specified period before the procedure.
- Medications may need adjustment or cessation.
- Pre-operative tests may include imaging studies, blood tests, and cardiovascular evaluations.
Procedure Description
- Anesthesia: The patient is given general anesthesia.
- Incisions: Surgical incisions are made in the chest (thoracotomy), abdomen, and neck.
- Esophagus Removal: The esophagus is carefully removed.
- Reconstruction: The stomach is pulled up to the neck and connected to the remaining portion of the esophagus (pharyngogastrostomy or cervical esophagogastrostomy).
- Optional Pyloroplasty: Sometimes, the pylorus (the opening between the stomach and small intestine) is modified to improve gastric emptying.
Tools and Equipment: Surgical instruments, retractors, and possibly robotic assistance.
Duration
The procedure typically takes 6 to 8 hours.
Setting
This surgery is performed in a hospital operating room.
Personnel
- Lead surgeon
- Surgical assistants
- Anesthesiologist
- Surgical nurses
- Intensive care unit staff (post-operatively)
Risks and Complications
- Bleeding
- Infection
- Anastomotic leaks (leakage at the surgical connection site)
- Respiratory complications
- Vocal cord injury
- Long-term swallowing difficulties
Benefits
- Removal of cancerous or damaged tissue
- Potential for cure or significantly improved quality of life
- Ability to swallow and eat foods normally
Recovery
- Hospital stay of 7-14 days typically required.
- Initial recovery involves intensive care followed by general ward care.
- Pain management includes medications and patient-controlled analgesia.
- Gradual reintroduction to diet, starting with liquids.
- Full recovery may take several months, with regular follow-up appointments.
Alternatives
- Chemotherapy and radiation therapy
- Endoscopic treatments for less advanced conditions
- Palliative care for non-operable cases
Pros and Cons of Alternatives: Less invasive but may be less effective for advanced cancer.
Patient Experience
During the procedure, the patient will be under general anesthesia and will not experience pain. Post-surgery, the patient may experience pain, discomfort, and difficulty swallowing initially, which is managed with medications. Emotional support and nutritional counseling might be beneficial.
Comprehensive pain management and comfort measures will be provided to ensure optimal recovery and support.