Continuing Education Care of Patients After Esophagectomyccn.aacnjournals.org/content/24/1/16.full.pdf · Her expertise is nursing care of postoperative patients. ... number of deaths,

16 CRITICALCARENURSE Vol 24, No. 1, FEBRUARY 2004

Donna J. Mackenzie works in the surgical intensive care unit in the Veterans Affairs Puget Sound Health Care System, Seattle, Wash,where she has been a staff nurse for the past 6 years. She has a special interest in the care of patients after esophagectomy and has devel-oped a teaching module for the nurses in her unit.

Pamela K. Popplewell is the clinical staff coordinator for the surgical wards and the progressive care unit in the Veterans Affairs PugetSound Health Care System. Her expertise is nursing care of postoperative patients. She is in the final year of a nurse practitioner pathwayat Seattle Pacific University.

Kevin G. Billingsley is a staff surgeon in the Veterans Affairs Puget Sound Health Care System and an assistant professor in the depart-ment of surgery at the University of Washington School of Medicine. His clinical and research interests focus on the multidisciplinarytreatment of patients with gastrointestinal tumors.

With approximately 12 000new cases diagnosed each year in theUnited States and a nearly equivalentnumber of deaths, esophageal cancerremains one of the most lethal of allmalignant diseases.1,2 The tumoroccurs more often in men than inwomen and more often in AfricanAmericans than in whites. The inci-dence of esophageal cancer increaseswith age.3,4

Squamous cell and adenocarci-noma are the 2 most common histo-pathologic forms of esophagealcancer. Squamous cell carcinoma

occurs more often in African Ameri-cans and Asians than in othergroups, and the incidence is higherin China, Japan, and Iran than inother countries.3 Squamous cell car-cinoma mainly occurs in the upperand middle parts of the esophagus.Adenocarcinoma arises mainly inthe distal part of the esophagus andat the gastroesophageal junction.Esophageal cancer may spread toother parts of the body via the bloodor lymphatic system. Distant metas-tases most often occur in the liverand lungs.3,5,6

CoverArticle

Authors

CE This article has been designated for CEcredit. A closed-book, multiple-choice examinationfollows this article, which tests your knowledge ofthe following objectives:

1. Identify the clinical findings associated with esophageal cancer

2. Describe the postoperative complications of esophagectomy

3. Discuss important aspects of nursing care of patients after esophagectomy

Donna J. Mackenzie, RN, BSN, CCRNPamela K. Popplewell, RN, MSN, CCRNKevin G. Billingsley, MD

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail,[email protected].

CEContinuing Education

Care of Patients After Esophagectomy

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EtiologyThe precise etiology of esophageal

cancer is not known. However, severalrisk factors are associated with itsoccurrence. Heavy alcohol use inconjunction with cigarette smokingor chewing tobacco is a major riskfactor for squamous cell cancer. Inareas of the world where esophagealcancer is endemic (eg, Iran, Russia,Puerto Rico, Singapore, China, Japan,and parts of Africa), dietary factorsare associated with increased risk ofesophageal cancer. In these countries,diets are high in nitrosamines, pick-led and fermented foods, and hotteas. Researchers speculate that thechronic mucosal inflammationcaused by drinking hot liquids andcreated by repeated exposure to tox-ins increases the likelihood of malig-nant transformation within cells ofthe esophageal mucosa.3,5

Another possible etiologic factorinvolved in the development ofesophageal cancer is chronic irritationof the esophageal mucosa related togastroesophageal acid reflux. Barrettesophagus develops in the distal partof the esophagus in a subset of patientswith chronic reflux.7 In this condition,the esophageal epithelial surface isaltered to become more like the stom-ach lining. This alteration, which isdescribed as columnar metaplasia, isassociated with a markedly increasedrisk of progression to adenocarci-noma. To detect changes within theesophagus before they progress tocancer, patients with known Barrett

hoarseness, coughing, sialorrhea(excessive salivation), and nocturnalaspiration.5,6,8,9

PrognosisThe overall prognosis for patients

with locally advanced esophagealcancer is poor. The age of the patient,the stage of cancer at diagnosis, andthe location of the tumor are all pre-dictors of survival.10 For patients withdisease extending through the wallof the esophagus and or involvementof regional lymph nodes, 5-year sur-vival is less than 15%.1

Surgical ManagementSurgical resection is the mainstay

of treatment for patients with local-ized esophageal cancer. However, inan effort to improve cure rates, chemo-therapy and radiation therapy areoften used in conjunction with sur-gery.11-14 We address the nursing careof patients who have surgical resec-tion of esophageal neoplasms andpatients who have prophylactic sur-gery for treatment of Barrett esopha-gus with high-grade dysplasia.

Preoperative EvaluationPatients may undergo multiple

diagnostic tests in preparation foresophageal surgery4 (Table 1). Thedefinitive diagnostic study forpatients suspected of having anesophageal tumor is flexible fiberop-tic esophagoscopy with biopsy. Aswell as indicating the presence ofdisease, a biopsy also can provideinformation about cell differentiation.

In addition to a biopsy, manypatients undergo computed tomog-raphy, positron emission tomogra-phy, and endoscopic ultrasound todetermine local stage and invasive-ness of the tumor and to survey for

esophagus should undergo regularendoscopic examinations andesophageal biopsies.

Recently, a genetic component ofesophageal cancer has been investi-gated. Overexpression and mutationof the gene that encodes the tumorsuppressor protein p53 have beenfound in esophageal cancer. Thisgenetic link is one of the most com-monly studied links associated withcancer development.3 Other tumorsuppressor genes may also be associ-ated with esophageal cancer.8

Clinical FindingsEarly-stage esophageal cancer is

rarely associated with notable signsand symptoms; therefore, early detec-tion is difficult.8 Dysphagia is themost common initial symptom butusually occurs in late-stage esophagealcancer.3 The esophagus is very pliable;

therefore, tumors are usually quiteadvanced before a person perceivesdifficulty with swallowing. By thetime patients go to a physician, theyoften have had dysphagia for severalmonths. It may have started with theinability to swallow solid foods andthen progressed eventually to liquids.They may have experienced signifi-cant weight loss, malnutrition, andweakness.3 In addition to dysphagia,patients with esophageal tumorsmay have pain with swallowing(odynophagia). Other late clinicalmanifestations of esophageal cancerare substernal pain, hiccups, respira-tory difficulty, heartburn, halitosis,


Early-stage esophageal cancer is rarelyassociated with significant symptoms andtherefore early detection is difficult



any local lymph node metastasis.3

Regional lymph nodes include lymphnodes in the mediastinum and nodesaround the gastric cardia and alongthe left gastric artery. Distant lymphnodes include lymph nodes aroundthe celiac axis and retroperitoneumand in the cervical (neck) chains.Involvement of these distant nodesis considered distant metastatic dis-ease (stage IV), and aggressive sur-gical treatment is generally notconsidered in patients with nodalinvolvement in these areas. Distantmetastases may also involve the liver,lungs, peritoneum, or adrenal glands.For patients with distant metastaticdisease, palliative chemotherapy,radiation therapy, or both are theprimary treatments.2 Once esophagealcancer is detected, it may be stagedby using the TNM (tumor-node-metastasis) classification system

(Table 2). In this system, tumors areclassified according to size, lymphnode involvement, and the presenceof metastases. The course of treatmentand the prognosis of the diseasedepend on the stage at diagnosis.Surgery for esophageal cancer maybe performed with either a curativeor palliative intent.16 See Table 3 forfactors that increase surgical risk.

Surgical TechniquesSurgical resection of the esopha-

gus for cancer is a technicallydemanding procedure. It usuallyinvolves removing part or all of theesophagus, part of the stomach,lymph nodes in the surroundingarea, and occasionally the spleen (ifit is injured or bleeding). Most com-

monly, the stomach is used to recon-struct the gastrointestinal tract. Ifthe entire esophagus and stomachmust be removed, part of the bowelis used to create a tube to maintaingastrointestinal continuity. Themost common surgical proceduresfor esophageal cancer are transhiatal

CRITICALCARENURSE Vol 24, No. 1, FEBRUARY 2004 19

Table 1 Preoperative diagnosticstudies for esophageal surgery

Blood and urine testsChemistry panel Complete blood cell countSerum albumin levelLiver function testsUrinalysis

Radiological studiesChest radiographyBarium swallowComputed tomography of the

abdomen Computed tomography of the

mediastinumBone scanEsophageal ultrasound for depth

of invasionPositron emission tomography

Cardiac and pulmonary studiesPulmonary function testsElectrocardiography

Tissue typing and tumor identificationCytology of tumor brushings or

biopsy specimensCervical lymph node biopsyEndoscopy with biopsy or brushingsBronchoscopy and laryngoscopy for

cervical or thoracic esophageallesions

Table 2 TNM staging system for esophageal carcinoma15

Primary tumor (T)Tx Primary tumor cannot be assessedT0 No evidence of primary tumor (eg, after treatment with radiation and chemotherapy)Tis Carcinoma in situT1 Tumor invades lamina propria or submucosa but not beyond itT2 Tumor invades muscularis propriaT3 Tumor invades adventitiaT4 Tumor invades adjacent structures (eg, aorta, tracheo-bronchial tree,

vertebral bodies, pericardium

Regional lymph nodes (N)Nx Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Regional node metastasis

Distant metastasis (M)Mx Presence of distant metastasis cannot be assessedM0 No distant metastasisM1 Distant metastasis

Stage groupingStage 0 Tis No MoStage 1 T1 No MoStage IIA T2 No MoStage IIB T1 N1 Mo

T2 N1 MoStage III T3 N1 Mo

T4 Any N MoStage IV Any T Any N M1

Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The origi-nal source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published bySpringer-Verlag New York, www.springer-ny.com.

Table 3 Factors that increase surgicalrisk in esophageal cancer17,18

Age >60 yearsChronic or recent illness, especially

pneumoniaObesity, smokingPoor nutritional statusExcessive alcohol consumptionUse of drugs such as antihypertensives,

muscle relaxants, tranquilizers, sleep inducers, insulin, sedatives, narcotics,β-adrenergic blockers, or cortisone



esophagectomy and transthoracicesophagectomy.

Transhiatal esophagectomyinvolves both an abdominal incisionand a cervical (neck) incision. Thethoracic cavity is not opened. Theabdominal component of the proce-dure involves complete mobilizationof the stomach. Lymph nodes aroundthe distal part of the esophagus, thegastric cardia, and the left gastricartery are resected in continuity withthe specimen. The intrathoracic partof the esophagus is then dissectedaway from adjacent thoracic struc-tures by using a blunt technique. Toperform this maneuver, the surgeonopens the diaphragmatic hiatus andmobilizes the esophagus by carefulmanual dissection up into the tho-racic cavity.19

The cervical component of theoperation involves opening the neckand retracting the sternocleidomas-toid muscle laterally. The part of theesophagus in the neck is encircledand dissected away from the adjacenttrachea. The esophagus is thendivided in the neck and passeddown through the chest. The upperpart of the stomach is then divided,and the specimen, which includesthe esophagus and the upper part ofthe stomach, is sent to the pathologylaboratory for examination. Gastroin-testinal continuity is reestablishedby constructing a tube out of theremaining part of the stomach andpassing the tube up through the chestand anastomosing the cervical partof the esophagus to the stomachtube20,21 (Figure 1).

Transthoracic esophagectomyinvolves an abdominal incision anda thoracotomy. The mid and lowerparts of the esophagus are removedalong with the upper part of the

in 1 second of less than 65% are atgreatest risk for postoperative pul-monary failure.17 Additional risk fac-tors for pulmonary complicationsinclude the patient’s age and per-formance status.23 For patients withpoor preoperative lung function, aperiod of preoperative cardiopul-monary rehabilitation should beconsidered.23

If the surgery is done to treatcancer, nearby lymph nodes also areremoved. Each operative approachhas strengths and weaknesses. Thetranshiatal esophagectomy sparespatients a thoracotomy incision, thusdiminishing postoperative pain andpulmonary complications.16 In addi-tion, the transhiatal esophagectomyplaces the esophageal anastomosishigh in the neck. If the anastomosisleaks in this position, the leak is easilymanaged by opening the neck incisionfor drainage. Doing so rarely resultsin systemic sepsis or mortality. Thetranshiatal approach, however, doesnot allow complete dissection of intra-thoracic lymph nodes and thus maylimit the surgeon’s ability to removeall disease-bearing lymph nodes.

In contrast, transthoracicesophagectomy involves a thoraco-tomy incision and requires placementof the anastomosis in the chest. If theanastomosis leaks in the chest, medi-astinitis, which may be life threaten-ing, often develops. The clearadvantage of the transthoracic pro-cedure is that the surgeon can dissectthe intrathoracic part of the esopha-gus and the regional mediastinalnodes under direct vision via thethoracotomy incision. Doing so pro-vides a theoretical advantage in dis-ease control. Results of a recent clinicaltrial suggest that the transthoracicprocedure may have a small advan-

stomach. The abdominal componentof the procedure involves completemobilization of the stomach. Thelymph nodes associated with the dis-tal part of the esophagus, the gastriccardia, and the left gastric artery areresected in continuity with the speci-men. When the stomach and the dis-tal part of the esophagus arecompletely dissected, the abdomi-nal incision is closed and the patientis repositioned for a right thoraco-tomy.22 Once the chest is opened, theintrathoracic part of the esophagusis dissected, and specimens of lymphnodes associated with the para-esophageal space and the subcarinalarea are obtained for pathologicalexamination. The esophagus isdivided in the chest. The upper partof the stomach is also divided, andthe specimen, which includes theesophagus and the upper part of thestomach, is sent for pathologicalexamination. In order to restore thegastrointestinal tract, the stomach isreconfigured, and a gastric tube iscreated and passed into the chest.The stomach is anastomosed to theesophagus in the chest cavity. Patientswho have transthoracic esophagec-tomy have no neck incision and haveone or more chest tubes postopera-tively21 (Figure 2).

The choice of operation dependson the location of the tumor, thepatient’s pulmonary function, and thesurgeon’s experience and preference.

Several investigators have stud-ied the preoperative factors that canbe used to predict postoperative pul-monary complications. One of themost consistent predictors of pul-monary complications is compro-mised preoperative lung function asindicated by spirometry.23 Patientswho have a forced expiratory volume





Figure 1 Transhiatal esophagectomy. A, Transhiatal mobilization of esophagus. B, Construction of gastric tube by using gastrointestinal anastomosing stapler. C, Formation of esophagogastric anastomosis.

Reprinted from Bolton et al,21 ©1998 with permission from Elsevier Science.

C

A

B

GIA staplerTumor

Left recurrentlaryngeal nerve



tage for disease control, althoughthis advantage was not statisticallysignificant in the analysis of overallsurvival rates.24

Enhanced nursing care thatincludes multisystem interventionssuch as aggressive pulmonary toilet;aggressive pain control; careful,skilled monitoring for potentialcomplications; preoperative andpostoperative teaching; and an inter-disciplinary, collaborative approachhas helped lower the mortality rateof esophagectomy patients. Gregoireand Fitzpatrick25 refer to this “morecomprehensive” nursing care andcredit it as a factor in enhancing sur-vival rates. Therefore, nurses play akey role in improving outcomes forthese patients.

Nursing Care of Patients After Esophagectomy

After esophagectomy, patientsgo to an intensive care unit for 24 to48 hours. They are usually intubatedand have multiple drains and tubes.These patients require intensive car-diopulmonary monitoring in the

ity in patients undergoing transtho-racic esophagectomy. Initial painmanagement may consist of mor-phine or bupivacaine given epidu-rally, patient-controlled analgesiawith morphine, or a combination ofboth, at the physician’s discretion.Pain should be reassessed as often asnecessary to ensure that it is undercontrol. Because these patientsreceive nothing by mouth for 5 to 7days, intravenous or epidural painmedications are used. Oral pain med-ications are started once an anasto-motic leak is ruled out on the fifth orseventh postoperative day and oncethe patient is tolerating an oral diet.The main classes of medication usedfor pain control include opioids,nonsteroidal anti-inflammatorydrugs, and local anesthetics. Non-pharmacological interventionsinclude heat/cold, massage, distrac-tion, relaxation, and positioning.28

Nurses should contact the pain serv-ice if they cannot relieve a patient’spain adequately.

Pulmonary CareThe risk of pulmonary complica-

tions is substantial after all esophagealsurgical procedures.29-31 Aggressivepulmonary toilet should be initiatedimmediately postoperatively to pre-vent atelectasis and pneumonia,major complications of esophagec-tomy.3 As addressed earlier, paincontrol is paramount in ensuringgood pulmonary toilet. Patients areusually intubated after surgery andmay or may not be extubated theevening of surgery. Atelectasis ornoncardiogenic pulmonary edemamay develop quickly after surgery.During the immediate postoperativeperiod, monitor oxygenation closelyand maintain vigilance for develop-

immediate postoperative period.4

Critical care nursing skills are vitalin the systematic assessment of thesepatients.

Neurological StatusAssess neurological status every

shift and more often if any changesfrom baseline occur. Even subtlechanges in neurological status mayindicate a postoperative complication.Decreased responsiveness, pupillarychanges, inability to move or unilat-eral weakness, agitation, inability tocontrol pain, or any neurologicalchange should be carefully watchedand promptly reported to a physi-cian if it persists.26

Pain Management Management of pain is key in

these patients, and adequate paincontrol reduces the mortality andmorbidity of patients after esophagec-tomy.27 In 1996, Tsui et al27 foundthat adequate pain control con-tributed to decreased cardiopul-monary complications, shorterhospital stay, and decreased mortal-


Figure 2 Transthoracic esophagectomy.

Reprinted from Bolton et al,21 ©1998 with permission from Elsevier Science.

Level 4node

Trachea

Azygosvein Level 7

node

Tumor

Level 8node

Esophagus

Thoracic ductAorta



ments that may be associated with asudden decrease in oxygenation.Patients may require suctioning, chestphysiotherapy, and nebulizers toimprove pulmonary status. Once apatient is extubated, initiate coughing,deep breathing exercises, and use ofthe incentive spirometer. Avoidnasotracheal suctioning because ofthe risk of passing a catheter throughthe new anastomosis.8,25 Teachpatients to splint their incision witha pillow. Early mobilization willassist in reducing the pulmonaryrisk of atelectasis, a precursor topneumonia.32 Monitor patientsclosely for fever.

Depending on the type of surgery,a chest tube may be in place. Forpatients with chest tubes, assess thedrainage every shift. The drainageshould become serosanguineouswithin a few hours. Expect no morethan 100 to 200 mL/h on the firstday. Drainage should decrease grad-ually. A sudden change in the colorof chest tube drainage may indicatean anastomotic leak and should becalled to the attention of a physician.25

Check the chest tube site for drainage,and keep the chest tube dressingclean, dry, and intact. Keep thechest tube free of any kinks ordependent loops,33 and palpate thesurrounding area for subcutaneousemphysema.9

If subcutaneous emphysemadoes develop, it is a harbinger ofpotentially significant complications,and the medical staff should be noti-fied. Subcutaneous emphysema maybe due to an air leak from a pleuralinjury sustained during the operation.Such an air leak is not necessarily ofgrave significance, but additionalsuction may be needed or placementof a new chest tube may be required.

Of greater concern, however, new-onset subcutaneous emphysemamay indicate a leak of the esophagealanastomosis. In such instances, airfrom the gastrointestinal tract dissectsupward through the mediastinumand manifests as subcutaneousemphysema in the chest and neck.Fever, tachycardia, and hypoxemiaalso may develop in patients withthis complication. Medical staffshould be notified immediately.Esophageal leak can be confirmed bya swallowing study with water-solu-ble contrast material.34 Postoperativechest radiographs should be checked

for pneumothorax and for place-ment of any chest tube.

Acute respiratory distress syn-drome can develop as soon as theevening of surgery. Patients are par-ticularly prone to acute respiratorydistress syndrome after transhiatalesophagectomy because the medi-astinal lymphatics, which drainpulmonary interstitial fluid, areextensively disrupted during the sur-gery. Although the mechanisms thatlead to the postoperative develop-ment of the syndrome are not fullyunderstood, the vigorous systemicinflammatory response that accom-panies the operation may play animportant role. This extensive medi-astinal dissection may also initiate ageneralized systemic inflammatoryresponse.35 Unfortunately, the com-plication of acute respiratory distresssyndrome remains difficult to predict,but all patients should be monitored

for abrupt changes in oxygenation inthe perioperative period.

HemodynamicsPatients are given intravenous

maintenance fluid (isotonic sodiumchloride solution or lactated Ringersolution) at a rate of 100 to 200 mL/hfor the first 12 to 16 hours after sur-gery. These fluids help maintain ade-quate circulating blood volume toprotect vital organs and ensure ade-quate blood supply to the newly cre-ated anastomosis. Major fluid shiftsoccur in the first few days after sur-gery, and hypovolemia may be a

problem.8 Patients may require fluidboluses in the immediate postopera-tive period. Crystalloids or bloodproducts may be used to restore cir-culating volume, but overloadingwith fluids must be avoided. Thelungs are already compromisedbecause lymph clearance has beendiminished by the surgical removalof the mediastinal lymphatics andnodes.25 Reduced clearance of lymphpredisposes these patients to inter-stitial pulmonary edema. Malnutri-tion and low protein levels can furthercomplicate the situation.

These patients require a delicatebalance between adequate fluidreplacement and fluid overload.8 Theextent and duration of the surgicalprocedure in esophagectomyinevitably results in transudation offluid into the interstitium. Therefore,patients need volume support andrehydration. However, because they


These patients require a delicate balancebetween adequate fluid replacement and

fluid overload



are also susceptible to pulmonaryedema, hydration should not beexcessive. In most instances, mainte-nance of 30 mL/h of urine output isevidence of adequate postoperativefluid resuscitation.

Determination of body weightand careful documentation of fluidintake and output should be donedaily. Patients usually have an arte-rial catheter in place. If their hemo-dynamic status is unstable, theymay have a pulmonary arterycatheter. Postoperative edema maybe significant, depending on theamount of fluid required to main-tain hemodynamic stability, someticulous skin care is necessary.Fluid in the tissues will seek outdependent areas and cause the skinin those areas to be at greater riskfor breakdown. When hemody-namic status is stable, patientsshould be turned at least every 2hours to assist in maintaining skinintegrity. Patients who cannot toler-ate frequent turning or who are dif-ficult to mobilize will need apressure-relieving surface.36

Nasogastric TubesIn general, all patients have a

nasogastric tube after esophagectomy.Do not move, manipulate, or irrigatethe nasogastric tube. If the tube comesout for any reason, do not attemptto replace it. The nasogastric tubegoes through the anastomosis and isnot sutured in place.9,19,22 Attemptingto replace the nasogastric tube mayresult in damage to the anastomosis.Be sure to notify a physician imme-diately if the tube becomes dislodgedor does not appear to be functioningproperly.25 Monitor the tube forpatency and assess the drainage forcolor and amount.

to start tube feedings via the jejunos-tomy tube or to start patients ontotal parenteral nutrition. If no leakis detected, patients are started on aclear liquid diet and advanced to softfoods as tolerated.3

Patients should be instructed toeat 6 to 8 small frequent meals eachday, because large meals may not bewell tolerated.3 Also, instructpatients to avoid very hot or coldbeverages and spicy foods. Proteinsupplements, high-energy foods, ora soft dysphagia diet may be indi-cated. A dietician is usually involvedin patients’ care, and laboratoryresults from a weekly nutritionalpanel can guide nutritional decisionmaking. Having patients sit upright,chew slowly, and eat more than 3hours before bedtime assists inreducing reflux.

Having patients drink fluidsbetween meals rather than with mealsassists in controlling signs and symp-toms of the dumping syndrome,which may arise in patients whohave had their vagus nerves divided.This common adverse effect aftervagotomy is related to unregulatedgastric emptying and rapid deliveryof carbohydrates and partiallydigested food products into thesmall intestine. Minimizing liquidswith meals and the consumption offrequent, small, low-carbohydratemeals also assists in controlling thesesigns and symptoms.3

Patients whose oral intake is notadequate by the time of dischargemay be discharged with plans forsupplemental tube feeding. Suchfeeding requires that patients orcaregivers be taught how to admin-ister tube feedings, and the correctsupplies must be ordered and givento the patients before discharge.

Gastrointestinal CareAfter esophagectomy, patients

are restricted from taking anythingby mouth for 5 to 7 days to preventan anastomotic leak or fistula forma-tion.25 Patients have nasogastric tubeswith low-level continuous or inter-mittent suction. Oral medications, ifordered, are crushed and put downthe nasogastric tube; they are neverswallowed. Diligent mouth careimproves patients’ comfort andreduces the risk for infection andshould be maintained while patientsare intubated and throughout theperiod when they cannot take any-thing by mouth.

A jejunostomy feeding tube isoften placed during surgery and isleft clamped until used.37 Flush thetube with 10 to 20 mL of isotonicsodium chloride solution every shift.Jejunostomy site care should be per-formed on a daily basis. Wash thesurrounding skin with a gentle soap,and assess the skin for any signs ofirritation or breakdown. Apply anon–petroleum-based protectiveointment, and make sure that thetube is well secured. Patients may ormay not be started on tube feedings2 to 3 days after surgery, dependingon the surgeon’s preference.38,39

Preoperatively, patients may havebeen receiving total parenteral nutri-tion or some other high-energy liquid supplement. If so, total par-enteral nutrition may be resumedafter surgery.

At 5 to 7 days after surgery, a flu-oroscopic swallowing examinationwith water-soluble contrast materialis done to check the anastomosis forleaks before oral intake of anythingis allowed.25 If a leak is suspected, analternative form of nutrition shouldbe started. The physician may choose




Genitourinary CarePatients have Foley catheters

draining to gravity after esophagec-tomy. Monitor fluid intake and outputhourly during the initial postopera-tive period. Call a physician if urineoutput is less than 30 mL/h for 2consecutive hours. Discontinue thecatheter as soon as possible to avoidurinary tract infections.

Incision CareKeep all dressings clean, dry,

and intact. The surgical dressing isremoved by a surgeon on postopera-tive day 2. Patients may have a neckincision, which can be opened by asurgeon at the bedside if an anasto-motic leak is suspected. Neck inci-sions that are opened up require wetto dry dressing changes 2 to 3 timesa day for several weeks, unless other-wise specified by the physician. Ininstances in which the anastomosishas separated, patients often havesaliva leaking out through the cervi-cal incision. Such leakage is oftenlow in volume and can be managedby simple dressing changes to theneck wound. However, if a patientis leaking saliva in large volumes(>250 mL every 8 hours), applica-tion of a wound drainage bag to thelower part of the neck incision maybe required. The leak is allowed toseal on its own, but sealing couldtake several weeks.

DrainsPatients may have a Jackson-

Pratt drain to bulb suction comingout of one of the incisions. Monitorthe amount and color of drainageeach shift. If the bulb drain will nothold suction, notify the medicalteam. A Penrose drain also may bein the neck incision. Change the

dressing for the Penrose drain as oftenas necessary to protect and maintainskin integrity around the drain.

Infection RiskPatients who have esophagec-

tomy have many potential sites ofinfection. They often have compro-mised nutritional status, they haveinvasive catheters in the early postop-erative period, and they have theusual risk of infection at the surgicalsites. Meticulous wound and skincare, hand washing, avoidance ofcross-contamination with organismsfrom other patients, and changing ofinvasive catheters per the facility’sprotocol assist in reducing thechance of infection. Judicious use ofantibiotics and adequate nutritionalso help avoid infection.

Prophylaxis of Deep Vein Thrombosis

Heparin shots are given subcuta-neously twice a day and compressionstockings are applied to both lowerextremities to prevent deep veinthrombosis. Until patients are ambu-lating independently, they shouldkeep the stockings on when in bed.Encourage early ambulation as wellas leg and ankle exercises. Early mobi-lization of patients includes gettingthem out of bed to a chair the firstpostoperative day and 3 times eachday thereafter.

Psychosocial AspectsDiagnosis of esophageal cancer

can be a devastating event in a per-son’s life. Patients may struggle withdepression, mortality, and fear pre-operatively, and most likely they willexperience some fear and anxietyafter surgery. Patients need supportand reassurance postoperatively.

They may fear mortality, have con-cerns about body image, or have feel-ings of guilt that their lifestyle habits(eg, smoking and drinking) may havecontributed to the development oftheir disease.4 Encourage them tofind a counselor with whom they canwork through these issues. In addi-tion, some patients may drool; caus-ing embarrassment and adding totheir feelings of isolation. Thesepatients need assistance in learningmethods to manage their secretions,such as using a portable suctiondevice, discreet use of tissues, andproper disposal of potentially infec-tious material.4

Offer explanations and supportto patients’ family members andfriends to promote healthy interac-tions with the patients. Encouragepatients to express their feelings andfears in a safe environment. Consideryour own filters or issues with theirdisease and possible causative factors.Help patients focus on the futureand set goals for a healthier diet andlifestyle. Offer community resourceswhen available (see list in “DischargeInstructions”).

Other ConsiderationsA high proportion of patients

who have esophageal surgery havea history of heavy smoking andalcohol use. Be aware of possibledelirium tremens on postoperativeday 3 or 72 hours after the patient’slast drink. Early identification (pre-operative) of patients at risk forsigns and symptoms of withdrawalis the best prevention, and earlytreatment is safest for both patientsand staff members. Benzodiazepines(most commonly lorazepam) areordered to manage alcohol with-drawal. For patients experiencing




Table 4 Postoperative complications of esophagectomy*

nicotine withdrawal, consider anicotine patch.

Postoperative ComplicationsEsophageal resection is an involved

operation with multiple potential com-plications, of which the nursing staff

postoperative complications ofesophagectomy, their signs andsymptoms, and management techniques. Prevention and earlydetection are the keys to successfulmanagement of postoperative com-plications.

and the physicians should be aware.The postoperative mortality rateassociated with esophagectomy pro-cedures ranges from 5% to 13%. Themost common causes of morbidityand mortality are cardiopulmonarycomplications. Table 4 lists possible


Complications

Esophageal anastomotic leak

Pneumonia, adult respiratorydistress syndrome, atelectasis

Deep vein thrombosis and/orpulmonary emboli

Gastric necrosis

Cardiac arrhythmias, myocardial infarction

Signs and symptoms Prevention strategies

Fever (≥38.6°C [101°F])Inflammation, painDrainage from the neck

wound or accumulation offluid at the wound site

Subcutaneous emphysemaUnexplained tachycardia or

tachypneaHypoxemiaChange in color of chest tube

drainage25

TachypneaDiminished breath soundsIncreased temperatureHypoxemiaPoor pulmonary complianceInterstitial infiltrates evident

on chest radiographDyspnea/shortness of breathChange in mentationConfusion

Difficulty breathingLeg swellingInflammation of involved legTachypneaArrhythmiasPain in leg

FeverOliguriaAcidosisTachycardiaHypotension

Atrial fibrillationContinuous supraventricular

tachycardiaChest painShortness of breathElectrocardiographic changesElevated cardiac enzyme

levels

Use skilled surgical techniques

Do not feed the patient tooearly

Maintain strict status of nooral intake

Manage pain adequatelyAvoid nasotracheal suctioning

after extubation14

Have patient stop smokingbefore surgery

Frequently turn patient, andprovide use of incentivespirometry, nebulizers

Chest physiotherapy,suctioning

Feed early after surgery38

Have patient ambulate earlyafter surgery

Have patient ambulate earlyafter surgery

Have patient do leg exercisesProvide antiembolism

stockings and sequentialcompression devices

Administer subcutaneousheparin

Use skilled surgical technique

Maintain adequate bloodpressure in perioperativeperiod

Maintain electrolyte balanceProvide adequate pain

managementMaintain normal body

temperatureMaintain hemoglobin level at

100 g/L (10 g/dL)orgreater25

Management

Use esophagography withwater-soluble contrastmaterial to diagnose theleak

Increase tube feedingsAfter several days, dilate the

esophagus if neededOpen neck wound at bedsideIrrigate and pack with wet-to-

dry dressingStop oral intake

Reintubate patient and provide respiratory supportas needed

Provide appropriate antibiotictherapy

Promote aggressive pulmonary toilet

Monitor arterial blood gases

Infuse heparinMaintain bed restUse a Greenfield filterProvide pulmonary support

Provide operative management

Administer digoxin, diltiazem,β-blockers

Use cardioversionReplace electrolytes Use percutaneous

transluminal coronary angioplasty

Provide oxygen therapyAdminister aspirinAdminister morphineAdminister nitroglycerin

Continued




Complications

Prolonged ileus

Wound infection

Sepsis

Gastrointestinal bleeding

Esophageal stenosis or anastomotic stricture

Diarrhea

Bleeding

Chylothorax

Signs and symptoms Prevention strategies

Lack of bowel soundsIncreased nasogastric tube

drainageNausea/vomitingNo evidence of bowel function

for more than 10 days aftersurgery

Decreased appetite

Redness at incisionIncreased pain at incisionFoul odor from woundSwelling at incisionDiscolored drainage from

incisionFever

Change in neurological statusConfusionDecreased systemic vascular

resistanceHypotension

Bloody drainage from nasogastric tube

Tarry stoolsDecreased hematocrit

Difficulty swallowing

Increased loose stoolsFluid and electrolyte

imbalancesWeakness and fatigue

HypotensionDecreased hematocrit

Milky white drainage from thechest tube

Provide adequate pain management with use ofnonnarcotic agents (non-steroidal anti-inflammatorydrugs)

Administer metoclopramideHave patient increase activity

level

Administer prophylacticantibiotics

Use sterile technique at timeof surgery

Maintain adequate tissue oxygenation during surgery

Maximize nutritional statuspreoperatively

Have staff use meticuloushand washing

Administer appropriate andtimely antibiotics

Administer fluidsMaintain strict hand washing

proceduresChange invasive catheters per

the facility’s protocol

Administer H2-blockers

Use meticulous surgical technique

Choose proper tube feedingHave patient drink liquids

between meals not withmeals

Have staff practice strict hand washing



Management

Administer metoclopramideGive stool softeners,

suppositories, enemas,bowel stimulants

Place a nasogastric tube (byphysician) to prevent vomiting

Open wound and start dressing changes

Administer systemic antibiotics if surroundingerythema significant

Treat underlying causeInsert a pulmonary artery

catheterAdminister vasoactive

medicationsAdminister antibioticsAdminister fluids

Give blood transfusionsDo endoscopy with

coagulationIntervene surgically if needed

Dilate the esophagus

Treat underlying causeAdminister loperamide before

mealsMonitor for infection with

Clostridium difficile

Give blood transfusionsAdminister intravenous fluidsSupport blood pressureIdentify sourceCorrect the causeIntervene surgically if needed

Monitor amount: if chyle output is 400-600 mL per8 hours continuously for 2-3 days, transthoracic ligation of the thoracic ductwill be required14

*If any complications are suspected, notify a physician immediately.

Table 4 Continued



Esophageal anastomotic leakageis the most serious postoperativecomplication and may occur 2 to 10days after surgery.3

Discharge InstructionsDischarge instructions for patients

and their families or caregivers shouldinclude the following:

• Take a few minutes each day toinspect the surgical incision for anysigns or symptoms of infection orother complications (increased pain,swelling, inflammation, fever,drainage, saliva leaking at incisionsite). Report any problems to yourdoctor immediately. See your doctorright away if you experience any dif-ficulty swallowing.

• Avoid smoking. You may find ithelpful to join a stop smoking supportgroup.

• Bathe and shower as usual.Wash the incision gently with a mildunscented soap.

• Avoid strenuous activity for 12weeks after surgery. You may resumeyour daily activities, work, and sexualrelations as soon as you feel able todo so. However, avoid driving for thefirst 3 weeks after returning home.

• Avoid coffee, tea, cocoa, coladrinks, alcoholic beverages, and anyfood or spices that cause indigestion.Try to eat 6 to 8 small meals a day.Avoid drinking liquids with meals toavoid rapid transit of food throughyour bowel. Drink fluids betweenmeals instead. Eating more than 3hours before bedtime will reducereflux.

• Weigh yourself several times aweek. Report any significant weightchanges to your doctor (>4.5 kg [10lb] in 2 weeks).

• Try not to take pain relieverslonger than 4 to 7 days. Talk with

3. Quinn KL, Reedy A. Esophageal cancer:therapeutic approaches and nursing care.Semin Oncol Nurs. 1999;15:17-25.

4. Held JL, Peahota A. Nursing care of patientswith esophageal cancer. Oncol Nurs Forum.1992;19:627-634.

5. Fisher T. Esophageal cancer. Centers for Dis-ease Control and Prevention. Available at:http://atoz.iqhealth.com/HealthAnswers/encyclopedia/HTMLfiles/2524.html.Accessed December 1, 2003.

6. McNamara JP. Esophageal cancer. Nursing82. March 1982;12:64.

7. National Cancer Institute. What you needto know about cancer of the esophagus.Available at: http://www.nci.nih.gov/cancerinfo/wyntk/esophagus. AccessedJanuary 17, 2003.

8. Sideranko S. Esophagogastrectomy. CritCare Nurs Clin North Am. 1993;5:177-184.

9. Hampton B, Dixon L, Wasson D, Bressler C,Caffery L. Esophageal and laryngeal can-cers: the continuum of care from hospital tohome. Symposium conducted at NationalTeaching Institute for Critical Care Nurses;May 2000; Orlando, Fla.

10. Billingsley KG, Maynard C, Schwartz DL,Dominitz JA. The use of trimodality therapyfor the treatment of operable esophagealcarcinoma in the veteran population. Cancer. 2001;92:1272-1279.

11. Walsh TN, Noonan N, Hollywood D, KellyA, Keeling N, Hennessy TP. A comparisonof multimodal therapy and surgery foresophageal adenocarcinoma. N Engl J Med.1996;335:462-467.

12. Minsky BD. Carcinoma of the esophagus, I:primary therapy. Oncology. 1999;13:1225-1232, 1235-1236.

13. Urba SG, Orringer MB, Turrisi A, Iannet-toni M, Forastiere A, Strawderman M. Ran-domized trial of preoperativechemoradiation versus surgery alone inpatients with locoregional esophageal carci-noma. J Clin Oncol. 2001;19:305-313.

14. Orringer MB. Transhiatal esophagectomy:avoiding and managing complications. Car-diothoracic Surgery Network. Available at:http://www.ctsnet.org/doc/106. AccessedMay 9, 2001.

15. American Joint Committee on Cancer.Esophageal cancer: TNM staging system.Available at: http://www.upmccancercenters.com/cancer/esophageal/tnm.cfm.Accessed February 12, 2003.

16. Orringer MB, Marshall B, Iannettoni MD.Transhiatal esophagectomy: clinical experi-ence and refinements. Ann Surg. 1999;230:392-403.

17. Avendano CE, Flume PA, Silvestri GA, KingLB, Reed CE. Pulmonary complicationsafter esophagectomy. Ann Thorac Surg.2002;73:922-926.

18. Nozoe T, Kimura Y, Ishida M, Saeki H,Korenaga D, Sugimachi K. Correlation ofpre-operative nutritional condition withpost-operative complications in surgicaltreatment for oesophageal carcinoma. Eur JSurg Oncol. 2002;28:396-400.

19. Trastek VF. Esophagectomy: transhiatal. In:Donohue JH, Van Heerden JA, Monson JRT,eds. Atlas of Surgical Oncology. Boston,Mass: Blackwell Science Inc; 1995:121-125.

20. Gandhi SK, Naunheim KS. Complicationsof transhiatal esophagectomy. Chest SurgClin North Am. 1997;7:601-612.

your doctor if you continue to havepain that requires pain medicationafter a few days. To prevent consti-pation, take stool softeners at leastas long as you take pain medication.If you are sent home with antibiotics,please take all of them even if youfeel fine. Crush all pills to promoteeasy swallowing.

• Notify your doctor if any of thefollowing occur: increased pain,swelling, redness, draining, orbleeding at the incisional site; vom-iting; excessive weakness; tarry(black) stools; new, unexplainedsymptoms (they may be adverseeffects of drugs used in treatment);unexplained progressive weight loss;or continuous diarrhea.

• Keep follow-up appointmentsso that your physician can monitoryour progress and condition.

The American Cancer Society,survival support groups, social work-ers, chaplains, counselors, and smok-ing (nicotine) cessation programs maybe helpful.8

ConclusionEsophageal cancer remains diffi-

cult to treat. Patients who undergoesophagectomy experiencedecreased morbidity and mortalitywith more comprehensive nursingcare. This article provides a basis fornurses to better understandesophageal cancer and the perioper-ative management of risks and com-plications of esophageal surgery.

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Thun M. Cancer statistics, 2001 [publishedcorrection appears in CA Cancer J Clin.2001;51:144]. CA Cancer J Clin. 2001;51:15-36.

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Donna J. Mackenzie, Pamela K. Popplewell and Kevin G. BillingsleyCare of Patients After Esophagectomy

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