Common questions and concerns expressed by patients
· What is an Esophagectomy?
· How can I live with only a portion of my esophagus?
· What kind of tests do I have before I have surgery?
· Is there anything I need to do before I am ready to have the surgery?
· What can I expect the day before my surgery?
· What else will I have before I leave the nursing unit and go to the operating room?
· Where do my family/friends wait while I am in surgery?
What is an Esophagectomy?
An esophagectomy is the surgical removal of the esophagus. The esophagus is the
thin walled tube that carries food from your mouth to your stomach. A portion of
this tube may be causing you difficulty due to narrowing or a growth blocking
the passage of food and liquids. Depending on what part of the esophagus is
affected, all or part of your esophagus may be removed. Either the stomach or a
section of your bowel (large intestines) may be brought up into your chest to
join with the esophagus that remains.
How can I live with only a portion of my esophagus?
Whatever is used to replace your esophagus (stomach or bowel) adjusts to become
the tube that transports food from your mouth to your stomach or small
intestines There are stitches (sutures) that hold these newly formed connections
(anastomoses). Before you can use your "new food tube", the
connections must heal.
What kind of tests do I have before I have surgery?
If your bowel is going to be used to replace your esophagus, you may need an
angiogram to check that the blood supply to the bowel is good. This is
important, since it will be removed and used as an esophagus replacement. You
may also need a barium enema to check that the bowel is healthy
If the stomach is going to be used, you may need an esophagoscopy. This allows the doctor to look at the esophagus and the stomach through a scope to be sure the stomach is healthy.
It is possible you will need additional tests, depending on the reason you are having the surgery. Your doctor or nurse will explain the reason for the tests.
Is there anything I need to do before I am ready to have the surgery?
There are number of things that need to be considered before your surgery.
Review this list with your "team" -your nurse, doctor, and family
members to find out what items apply to you.
The health of your lungs is very important before your surgery.
· If you smoke, YOU MUST STOP SMOKING NOW! Please let your doctor or nurse know if you need help quitting.
· If your lungs are congested, you will need to use the incentive spirometer (device for deep breathing) as advised by your doctor.
· If your lung function needs to be improved, your doctor may recommend outpatient pulmonary rehabilitation.
Depending on the health of your heart and medical history, your doctor may recommend the following.
· An appointment with a cardiologist (heart doctor) for evaluation.
· ECG (electrocardiogram), thallium stress test, or cardiopulmonary stress test.
Prepare for healing after surgery by being as nutritionally sound as possible.
· The dietitian will assess your nutritional status. She may have you keep food diaries or recommend supplements. She will watch your weight and blood values before surgery. If you have lost a lot of weight because of the problem with your esophagus, you may require a feeding tube. A feeding tube is a soft tube that goes through your nose into your stomach. Liquid nutrition will be pumped into the tube. This will provide additional calories to help prevent weight loss and ensure adequate nutrition.
Have any infections in your mouth taken care of before your surgery. Let your doctor know about any gum infections or unfilled cavities.
What can I expect the day before my surgery?
There are a number of things that will be done once you are admitted to the
hospital.
Empty all of the stool from your bowel before you go to surgery. Your bowel must be clean if it is going to replace your esophagus. Even if the plan is to use your stomach, your doctor will order the bowel prep. To empty the stool from your bowels:
· Eat and drink only clear liquids after breakfast. Clear liquids are fluids you can "see through" such as tea, Jell-O, and broth.
· Drink a bowel cleanser. It is a gallon of liquid you drink so it has time to work before you go to sleep.
· Take enemas (a flushing of the large bowel with water) the night before surgery and the morning of your surgery to clean any stool that remains in your bowel.
Decrease the bacteria in your gastrointestinal tract (mouth, esophagus, stomach, and bowels) -
GIT sterilisation is a controversial area
Keep your stomach empty before surgery.
· Beginning at midnight, you are to have NOTHING to eat or drink. This is called "NPO" or "NBM" "nothing by mouth (per os)".
Meet with an anesthetist. This doctor, who specializes in delivering anesthesia, will assess you and your medical history. He or she will explain the type of anesthesia that will be used for your operation.
What else will I have before I go to the operating room?
Whenever you have surgery, you are at risk of getting blood clots in your legs. To prevent clots from forming.
· Support hose or anti-embolism (prevent blood clot) stockings will be put on your legs. These are snug hose that go up to your thigh. They are used to improve the flow of blood. It is very important to keep them pulled up. Don't let them roll down your legs. They may cause decreased blood flow or skin breakdown if they are not kept pulled up and smooth.
· Sequential compression devices are also used. They are plastic sleeves that wrap around your legs. They stay in place with Velcro. The sleeves are attached to a pump. The pump fills the sleeves with air and gently squeezes the leg, squeezing from ankle to calf to thigh. These help the circulation in the legs.
Before you leave for the operating room, your nurse will be sure you have:
· Brushed your teeth and bathed. Emptied your bladder. Put on a hospital gown. Removed your underwear.
· Removed nail polish, hairpins, jewelry, makeup, glasses, contacts, hearing aids and dentures/partials.
Where do my family/friends wait while I am in surgery?
This obviously depends on the unit you work in. You can gain a lot of patient
respect by phoning or speaking to the relatives after the operation to explain
how things went.
· Do I go back to the unit that I was on before surgery?
· What kind of equipment will I have?
· How many incisions will I have and where will they be?
· How does pain control assist in my recovery?
· What type of pain control measures are available?
· What are the most important things can I do to help in my recovery?
· When will the NG tube be removed?
· When will the chest tube be removed?
· What happens after I start the small meals of a soft diet?
· Why all the attention to the eating and calorie counts?
Do I go back to the unit that I was on before surgery?
You will go back to the unit you were on before surgery, but not right away.
Most patients go to the SICU (Surgical Intensive Care Unit) or the HDU (High
dependency unit) for the first day or two. In the SICU or HDU, the nurses and
doctors will watch your heart and lung status very closely. Also, your vital
signs (temperature, heart rate, respiratory rate and blood pressure) will be
checked often.
What kind of equipment will I have?
Right after surgery you will have the following monitoring equipment and tubes:
Heart monitor - watches for any changes in your heart. Leads (sticky patches on your skin) on your chest attach to a monitor much like a TV screen so your heart's activity can be watched.
Oxygen saturation - reports how much oxygen your blood is carrying. It is sometimes called an "02 sat." A probe is attached to your finger, earlobe, or forehead. The probe goes to a machine that shows a number. A normal "02 sat" is 95-100%, but can vary depending on the your medical history.
Urinary catheter or "foley catheter" - is a tube that is placed in your urinary bladder during surgery. It drains the urine as your kidneys make it. Your nurse and doctor will be watching your fluid balance (also called Intake and Output or "I's and O's").
Nasogastric tube or "NG" tube - is a tube that goes through your nose and into your stomach. The tube is taped to your nose and pinned to your gown so that it doesn't move. If it moves, it can make your nostril sore or the tube could come out.
The NG tube is VERY important. It must not get moved! It will have suction applied to it to remove the secretions and gas that collect in your stomach or bowel after surgery. This prevents bloating that can cause tension on the suture lines. The suture line is where the surgeon has sewn the remaining esophagus to the stomach or bowel. If the bowel was used, there would be a suture line in the bowels as well.
Tell your nurse if you feel nauseated or if you vomit. The NG tube may need to be checked by the doctor.
Chest tube - is a tube that is placed in your chest during surgery. It comes out of the chest near the chest incision. It is stitched to your skin so it stays in place. The chest tube removes drainage and air from the chest cavity. It allows the lungs to re-expand. It also plays another very important role. It helps detect if there is a leak where the esophagus and stomach (or bowel) are sewn together.
Jackson Pratt drain or JP drain - AN OPTIONAL EXTRA - is a soft tube near each internal suture line (anastomosis) placed during surgery. This is where the remaining esophagus is sewn to the stomach (or bowel). The drain comes through the surface of your skin. Like the chest tube, its job is to help the nurses and doctor watch for signs that the suture line is not holding or "leaking". To help pull the drainage from inside the body, the JP is attached to a bulb. The bulb provides gentle suction. The JP is stitched to your skin so it stays in place.
Jejunostomy tube or J-tube - AN OPTIONAL EXTRA depending on your unit - is a soft rubber tube that is placed into your jejunum (small bowel) during surgery. The tube comes through the surface of your abdomen. It is stitched at the skin so it doesn't fallout accidentally. This tube is very important, since it is the way you will receive your nutrition. Until your internal suture lines are healed, you can't eat or drink anything not even ice or clear liquids.
Feedings (liquid nutrition)
will be placed into your small intestine through the J-tube. They will be
started once there are signs that your bowels have become active after surgery,
usually two to three days. The nurse or doctor know your bowels are active
because they either hear bowel sounds or you
are passing gas rectally.
You will receive nutritional liquid through the J-tube so your body gets the calories, protein, fat, and carbohydrates it needs for healing. You will begin with feedings 24 hours a day. Once you are able to eat, the feedings will only be done at night while you are sleeping. The J-tube feeding will continue until you are able to eat enough calories to sustain you and help your body to heal. This could be as long as 2 - 3 months after surgery.
How many incisions will I have and where will they be?
The location of your incisions depends on what part of the esophagus has been
removed.
Usually there will be two incisions.
How does pain control assist in my recovery?
Keeping your pain under control helps you recover from your surgery since it
makes it easier for you to:
Your nurse will be asking you to rate your pain. You must tell your nurse or doctor if your pain is not well controlled. The Pain Service will be assisting in the management of your pain. There are number of pain control measures available.
What type of pain control measures are available?
There are a number of ways your pain may be controlled:
What are the most important things can I do to help in my recovery?
When will the NG tube be removed?
The tube will not be removed until it is certain that there is no leak at the
incision site. Usually around 7 - 10 days after surgery, a swallow test is
performed to see if there is any leaking around the incision site.
If there isn't any leaking, and the stomach is emptying properly, the tube will be removed. You will only be allowed to drink grape juice until the next day. If there is no sign of leaking, you will start on liquid diet, and increase it gradually until you are eating a soft diet of 5 small meals per day.
If there is leaking, the NG tube will remain until the site is well healed. It is important not to eat or drink anything when there is a leak because it will drain into the lungs and surrounding tissues, causing infections and pneumonia.
When will the chest tube be removed?
After you have been drinking and there isn't any sign of a leak, your chest tube
may be removed.
What happens after I start the small meals of a soft diet?
After you have started eating by mouth and are tolerating food, your daytime
tube fee dings will stop. The staff will watch how much you are able to eat by
doing a "calorie count". During this time, your tube fee dings will
only be on during the night.
Why all the attention to the eating and calorie counts?
It is very important for your healing and recovery that you take in enough
calories. Your calorie count, body weight and some blood work will help us see
how nutritionally sound you are.
When you get home, you will also be keeping a food diary to bring to your clinic visit. The dietitian will look at it. Depending on your intake and weight, your feedings will be adjusted. Your tube feedings will be decreased as you increase the food you take in by mouth. Over a period of a few months, you will be weaned from the tube feedings. The feeding tube will be left in for one month after you are taking all your nutrition by mouth to make sure you can maintain your weight and will not need to restart the tube feedings.
· Who will I need to talk to before I leave the hospital?
· What will I need to have at home when I am discharged from the hospital?
· What kind of care do I need to do with a jejunostomy tube at home?
· What type of problems with the J-tube should I report to my doctor?
· When I am at home, is there anytime I should call back to my doctors?
· How do you keep my local doctor updated on what is happening with me?
Who will I need to talk to before I leave the hospital?
A dietitian will discuss your diet. A social worker will help arrange for a
visiting nurse and any equipment you will need at home. If you have your
medication prescriptions filled at the hospital, a pharmacist will discuss your
medications with you. A physical therapist will review your home exercise
program. A nurse will explain instructions for your care at home.
What will I need to have at home when I am discharged from the hospital?
Each patient will have a plan specific for his/her needs. You and your family
members will discuss your needs with the nurse, doctor, dietitian and social
worker. The usual issues/concerns that need to be arranged for before you go
home are:
Tube feedings require formula, a machine to keep the feeding at the right rate, bags and tubing to give the feeding and medicines. You and your caregiver will be instructed on how to give your tube feedings.
Incision care and the supplies you need will be explained if incision care is necessary.
6" concrete blocks will need to be placed under the legs at the top of your bed. Raising the top of your bed will help to prevent slumping, acid reflux and aspiration.
Outpatient rehabilitation will be needed to help you gain back as much lung function and physical strength as possible.
Home issues such as:
· General safety issues in the home — going up and down steps, non-skid rugs, a chair to sit on in the shower, getting in and out of the shower/tub, etc.
· Help with daily needs — laundry, preparing meals, shopping, housekeeping, etc.
What kind of care do I need to do with a jejunostomy tube at home?
You will need to learn how to take care of your jejunostomy tube while you are
here so you can take care of it at home.
Skin care around the J-tube
The skin around the tube needs to be cared for. It should be washed daily with
soap and water. You may shower. Hydrogen peroxide may be used if there is
crusting or thick drainage to remove. Rinse thoroughly with soap and water. You
may use a light dressing if there is still drainage. It should be left open to
air if it is not draining.
Night-time tube feedings
Patients will need liquid feeding through the tube at home for a short period of
time. The nurses and the social worker will help arrange for your feedings,
feeding pump and instruction on the use of the pump at home. We also will
arrange for a visiting nurse to help until you are comfortable with using the
equipment. We will teach you as much as we can while you are in the hospital.
The company that supplies the pump will instruct you at home and be available
for assistance. The visiting nurse will also be available to assist you in
caring for your tube at home.
Medications through the
J-tube
If you are giving medications through the J-tube, it is very important to flush
the tube with 30 cc water between each medication and after the last medication.
You do not want the medications to mix with each other or mix with the feeding
in the tube. This may cause your tube to become clogged.
J-tube that is not being
used
If you are not using your tube, it will be left in place (for about a month)
until the doctor and dietitian are sure you are eating enough by mouth. During
that time, your tube will need to be flushed once a day with 30 cc of water to
keep the tube open if it is needed in the future.
What type of problems with the J-tube should I report to my doctor?
Notify your doctor if at any time if you:
When I am at home, is there anytime I should
call back to my doctors ?
Call before going to see your local doctor unless it is an emergency.
Call immediately if you have the following:
How do you keep my local doctor updated on what
is happening with me?
Letters are sent to local doctors: 1) after clinic appointments, 2) after
surgical procedures, 3) after discharge from the hospital, and 4) as needed.