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Critical Care Nurse. 2004;24: 16-29
Copyright © 2004 by the American Association of Critical-Care Nurses.
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Cover Article
CE Article

Care of Patients After Esophagectomy

Donna J. Mackenzie, RN, BSN, CCRN
 Pamela K. Popplewell, RN, MSN, CCRN
 Kevin G. Billingsley, MD

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 developed 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 Puget Sound Health Care System. Her expertise is nursing care of postoperative patients. She is in the final year of a nurse practitioner pathway at 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 department of surgery at the University of Washington School of Medicine. His clinical and research interests focus on the multidisciplinary treatment of patients with gastrointestinal tumors.

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, reprints{at}aacn.org.

This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the 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

With approximately 12000 new cases diagnosed each year in the United States and a nearly equivalent number of deaths, esophageal cancer remains one of the most lethal of all malignant diseases.1,2 The tumor occurs more often in men than in women and more often in African Americans than in whites. The incidence of esophageal cancer increases with age.3,4

Squamous cell and adenocarcinoma are the 2 most common histopathologic forms of esophageal cancer. Squamous cell carcinoma occurs more often in African Americans and Asians than in other groups, and the incidence is higher in China, Japan, and Iran than in other countries.3 Squamous cell carcinoma mainly occurs in the upper and middle parts of the esophagus. Adenocarcinoma arises mainly in the distal part of the esophagus and at the gastroesophageal junction. Esophageal cancer may spread to other parts of the body via the blood or lymphatic system. Distant metastases most often occur in the liver and lungs.3,5,6


   Etiology
Top
 Etiology
Clinical Findings
 Prognosis
 Surgical Management
 Nursing Care of Patients...
 Discharge Instructions
 Conclusion
 References
 
The precise etiology of esophageal cancer is not known. However, several risk factors are associated with its occurrence. Heavy alcohol use in conjunction with cigarette smoking or chewing tobacco is a major risk factor for squamous cell cancer. In areas of the world where esophageal cancer is endemic (eg, Iran, Russia, Puerto Rico, Singapore, China, Japan, and parts of Africa), dietary factors are associated with increased risk of esophageal cancer. In these countries, diets are high in nitrosamines, pickled and fermented foods, and hot teas. Researchers speculate that the chronic mucosal inflammation caused by drinking hot liquids and created by repeated exposure to toxins increases the likelihood of malignant transformation within cells of the esophageal mucosa.3,5

Another possible etiologic factor involved in the development of esophageal cancer is chronic irritation of the esophageal mucosa related to gastroesophageal acid reflux. Barrett esophagus develops in the distal part of the esophagus in a subset of patients with chronic reflux.7 In this condition, the esophageal epithelial surface is altered to become more like the stomach lining. This alteration, which is described as columnar metaplasia, is associated with a markedly increased risk of progression to adenocarcinoma. To detect changes within the esophagus before they progress to cancer, patients with known Barrett esophagus should undergo regular endoscopic examinations and esophageal biopsies.

Recently, a genetic component of esophageal cancer has been investigated. Overexpression and mutation of the gene that encodes the tumor suppressor protein p53 have been found in esophageal cancer. This genetic link is one of the most commonly studied links associated with cancer development.3 Other tumor suppressor genes may also be associated with esophageal cancer.8


   Clinical Findings
Top
 Etiology
 Clinical Findings
Prognosis
 Surgical Management
 Nursing Care of Patients...
 Discharge Instructions
 Conclusion
 References
 
Early-stage esophageal cancer is rarely associated with notable signs and symptoms; therefore, early detection is difficult.8 Dysphagia is the most common initial symptom but usually occurs in late-stage esophageal cancer.3 The esophagus is very pliable; therefore, tumors are usually quite advanced before a person perceives difficulty with swallowing. By the time patients go to a physician, they often have had dysphagia for several months. It may have started with the inability to swallow solid foods and then progressed eventually to liquids. They may have experienced significant weight loss, malnutrition, and weakness.3 In addition to dysphagia, patients with esophageal tumors may have pain with swallowing (odynophagia). Other late clinical manifestations of esophageal cancer are substernal pain, hiccups, respiratory difficulty, heartburn, halitosis, hoarseness, coughing, sialorrhea (excessive salivation), and nocturnal aspiration.5,6,8,9


   Prognosis
Top
 Etiology
 Clinical Findings
 Prognosis
Surgical Management
 Nursing Care of Patients...
 Discharge Instructions
 Conclusion
 References
 
The overall prognosis for patients with locally advanced esophageal cancer is poor. The age of the patient, the stage of cancer at diagnosis, and the location of the tumor are all predictors of survival.10 For patients with disease extending through the wall of the esophagus and or involvement of regional lymph nodes, 5-year survival is less than 15%.1


   Surgical Management
Top
 Etiology
 Clinical Findings
 Prognosis
 Surgical Management
Nursing Care of Patients...
 Discharge Instructions
 Conclusion
 References
 
Surgical resection is the mainstay of treatment for patients with localized esophageal cancer. However, in an effort to improve cure rates, chemotherapy and radiation therapy are often used in conjunction with surgery.11–14 We address the nursing care of patients who have surgical resection of esophageal neoplasms and patients who have prophylactic surgery for treatment of Barrett esophagus with high-grade dysplasia.

Preoperative Evaluation
Patients may undergo multiple diagnostic tests in preparation for esophageal surgery4 (Table 1Go). The definitive diagnostic study for patients suspected of having an esophageal tumor is flexible fiberoptic esophagoscopy with biopsy. As well as indicating the presence of disease, a biopsy also can provide information about cell differentiation.


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  		Table 1 Preoperative diagnostic studies for esophageal surgery

 
In addition to a biopsy, many patients undergo computed tomography, positron emission tomography, and endoscopic ultrasound to determine local stage and invasiveness of the tumor and to survey for any local lymph node metastasis.3 Regional lymph nodes include lymph nodes in the mediastinum and nodes around the gastric cardia and along the left gastric artery. Distant lymph nodes include lymph nodes around the celiac axis and retroperitoneum and in the cervical (neck) chains. Involvement of these distant nodes is considered distant metastatic disease (stage IV), and aggressive surgical treatment is generally not considered in patients with nodal involvement in these areas. Distant metastases may also involve the liver, lungs, peritoneum, or adrenal glands. For patients with distant metastatic disease, palliative chemotherapy, radiation therapy, or both are the primary treatments.2 Once esophageal cancer is detected, it may be staged by using the TNM (tumor-node-metastasis) classification system (Table 2Go). In this system, tumors are classified according to size, lymph node involvement, and the presence of metastases. The course of treatment and the prognosis of the disease depend on the stage at diagnosis. Surgery for esophageal cancer may be performed with either a curative or palliative intent.16 See Table 3Go for factors that increase surgical risk.


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  		Table 2 TNM staging system for esophageal carcinoma15

 

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  		Table 3 Factors that increase surgical risk in esophageal cancer17,18

 
Surgical Techniques
Surgical resection of the esophagus for cancer is a technically demanding procedure. It usually involves removing part or all of the esophagus, part of the stomach, lymph nodes in the surrounding area, and occasionally the spleen (if it is injured or bleeding). Most commonly, the stomach is used to reconstruct the gastrointestinal tract. If the entire esophagus and stomach must be removed, part of the bowel is used to create a tube to maintain gastrointestinal continuity. The most common surgical procedures for esophageal cancer are transhiatal esophagectomy and transthoracic esophagectomy.

Transhiatal esophagectomy involves both an abdominal incision and a cervical (neck) incision. The thoracic cavity is not opened. The abdominal component of the procedure involves complete mobilization of the stomach. Lymph nodes around the distal part of the esophagus, the gastric cardia, and the left gastric artery are resected in continuity with the specimen. The intrathoracic part of the esophagus is then dissected away from adjacent thoracic structures by using a blunt technique. To perform this maneuver, the surgeon opens the diaphragmatic hiatus and mobilizes the esophagus by careful manual dissection up into the thoracic cavity.19

The cervical component of the operation involves opening the neck and retracting the sternocleidomastoid muscle laterally. The part of the esophagus in the neck is encircled and dissected away from the adjacent trachea. The esophagus is then divided in the neck and passed down through the chest. The upper part of the stomach is then divided, and the specimen, which includes the esophagus and the upper part of the stomach, is sent to the pathology laboratory for examination. Gastrointestinal continuity is reestablished by constructing a tube out of the remaining part of the stomach and passing the tube up through the chest and anastomosing the cervical part of the esophagus to the stomach tube20,21 (Figure 1Go).



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

 
Transthoracic esophagectomy involves an abdominal incision and a thoracotomy. The mid and lower parts of the esophagus are removed along with the upper part of the stomach. The abdominal component of the procedure involves complete mobilization of the stomach. The lymph nodes associated with the distal part of the esophagus, the gastric cardia, and the left gastric artery are resected in continuity with the specimen. When the stomach and the distal part of the esophagus are completely dissected, the abdominal incision is closed and the patient is repositioned for a right thoracotomy.22 Once the chest is opened, the intrathoracic part of the esophagus is dissected, and specimens of lymph nodes associated with the para-esophageal space and the subcarinal area are obtained for pathological examination. The esophagus is divided in the chest. The upper part of the stomach is also divided, and the specimen, which includes the esophagus and the upper part of the stomach, is sent for pathological examination. In order to restore the gastrointestinal tract, the stomach is reconfigured, and a gastric tube is created and passed into the chest. The stomach is anastomosed to the esophagus in the chest cavity. Patients who have transthoracic esophagectomy have no neck incision and have one or more chest tubes postoperatively21 (Figure 2Go).



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  		Figure 2 Transthoracic esophagectomy.

 
The choice of operation depends on the location of the tumor, the patient’s pulmonary function, and the surgeon’s experience and preference.

Several investigators have studied the preoperative factors that can be used to predict postoperative pulmonary complications. One of the most consistent predictors of pulmonary complications is compromised preoperative lung function as indicated by spirometry.23 Patients who have a forced expiratory volume in 1 second of less than 65% are at greatest risk for postoperative pulmonary failure.17 Additional risk factors for pulmonary complications include the patient’s age and performance status.23 For patients with poor preoperative lung function, a period of preoperative cardiopulmonary rehabilitation should be considered.23

If the surgery is done to treat cancer, nearby lymph nodes also are removed. Each operative approach has strengths and weaknesses. The transhiatal esophagectomy spares patients a thoracotomy incision, thus diminishing postoperative pain and pulmonary complications.16 In addition, the transhiatal esophagectomy places the esophageal anastomosis high in the neck. If the anastomosis leaks in this position, the leak is easily managed by opening the neck incision for drainage. Doing so rarely results in systemic sepsis or mortality. The transhiatal approach, however, does not allow complete dissection of intra-thoracic lymph nodes and thus may limit the surgeon’s ability to remove all disease-bearing lymph nodes.

In contrast, transthoracic esophagectomy involves a thoracotomy incision and requires placement of the anastomosis in the chest. If the anastomosis leaks in the chest, mediastinitis, which may be life threatening, often develops. The clear advantage of the transthoracic procedure is that the surgeon can dissect the intrathoracic part of the esophagus and the regional mediastinal nodes under direct vision via the thoracotomy incision. Doing so provides a theoretical advantage in disease control. Results of a recent clinical trial suggest that the transthoracic procedure may have a small advantage for disease control, although this advantage was not statistically significant in the analysis of overall survival rates.24

Enhanced nursing care that includes multisystem interventions such as aggressive pulmonary toilet; aggressive pain control; careful, skilled monitoring for potential complications; preoperative and postoperative teaching; and an interdisciplinary, collaborative approach has helped lower the mortality rate of esophagectomy patients. Gregoire and Fitzpatrick25 refer to this "more comprehensive" nursing care and credit it as a factor in enhancing survival rates. Therefore, nurses play a key role in improving outcomes for these patients.


   Nursing Care of Patients After Esophagectomy
Top
 Etiology
 Clinical Findings
 Prognosis
 Surgical Management
 Nursing Care of Patients...
Discharge Instructions
 Conclusion
 References
 
After esophagectomy, patients go to an intensive care unit for 24 to 48 hours. They are usually intubated and have multiple drains and tubes. These patients require intensive cardiopulmonary monitoring in the immediate postoperative period.4 Critical care nursing skills are vital in the systematic assessment of these patients.

Neurological Status
Assess neurological status every shift and more often if any changes from baseline occur. Even subtle changes in neurological status may indicate a postoperative complication. Decreased responsiveness, pupillary changes, inability to move or unilateral weakness, agitation, inability to control pain, or any neurological change should be carefully watched and promptly reported to a physician if it persists.26

Pain Management
Management of pain is key in these patients, and adequate pain control reduces the mortality and morbidity of patients after esophagectomy.27 In 1996, Tsui et al27 found that adequate pain control contributed to decreased cardiopulmonary complications, shorter hospital stay, and decreased mortality in patients undergoing transthoracic esophagectomy. Initial pain management may consist of morphine or bupivacaine given epidurally, patient-controlled analgesia with morphine, or a combination of both, at the physician’s discretion. Pain should be reassessed as often as necessary to ensure that it is under control. Because these patients receive nothing by mouth for 5 to 7 days, intravenous or epidural pain medications are used. Oral pain medications are started once an anastomotic leak is ruled out on the fifth or seventh postoperative day and once the patient is tolerating an oral diet. The main classes of medication used for pain control include opioids, nonsteroidal anti-inflammatory drugs, and local anesthetics. Non-pharmacological interventions include heat/cold, massage, distraction, relaxation, and positioning.28 Nurses should contact the pain service if they cannot relieve a patient’s pain adequately.

Pulmonary Care
The risk of pulmonary complications is substantial after all esophageal surgical procedures.29–31 Aggressive pulmonary toilet should be initiated immediately postoperatively to prevent atelectasis and pneumonia, major complications of esophagectomy.3 As addressed earlier, pain control is paramount in ensuring good pulmonary toilet. Patients are usually intubated after surgery and may or may not be extubated the evening of surgery. Atelectasis or noncardiogenic pulmonary edema may develop quickly after surgery. During the immediate postoperative period, monitor oxygenation closely and maintain vigilance for developments that may be associated with a sudden decrease in oxygenation. Patients may require suctioning, chest physiotherapy, and nebulizers to improve pulmonary status. Once a patient is extubated, initiate coughing, deep breathing exercises, and use of the incentive spirometer. Avoid nasotracheal suctioning because of the risk of passing a catheter through the new anastomosis.8,25 Teach patients to splint their incision with a pillow. Early mobilization will assist in reducing the pulmonary risk of atelectasis, a precursor to pneumonia.32 Monitor patients closely for fever.

Depending on the type of surgery, a chest tube may be in place. For patients with chest tubes, assess the drainage every shift. The drainage should become serosanguineous within a few hours. Expect no more than 100 to 200 mL/h on the first day. Drainage should decrease gradually. A sudden change in the color of chest tube drainage may indicate an anastomotic leak and should be called to the attention of a physician.25 Check the chest tube site for drainage, and keep the chest tube dressing clean, dry, and intact. Keep the chest tube free of any kinks or dependent loops,33 and palpate the surrounding area for subcutaneous emphysema.9

If subcutaneous emphysema does develop, it is a harbinger of potentially significant complications, and the medical staff should be notified. Subcutaneous emphysema may be due to an air leak from a pleural injury sustained during the operation. Such an air leak is not necessarily of grave significance, but additional suction may be needed or placement of a new chest tube may be required. Of greater concern, however, new-onset subcutaneous emphysema may indicate a leak of the esophageal anastomosis. In such instances, air from the gastrointestinal tract dissects upward through the mediastinum and manifests as subcutaneous emphysema in the chest and neck. Fever, tachycardia, and hypoxemia also may develop in patients with this complication. Medical staff should be notified immediately. Esophageal leak can be confirmed by a swallowing study with water-soluble contrast material.34 Postoperative chest radiographs should be checked for pneumothorax and for placement of any chest tube.

Acute respiratory distress syndrome can develop as soon as the evening of surgery. Patients are particularly prone to acute respiratory distress syndrome after transhiatal esophagectomy because the mediastinal lymphatics, which drain pulmonary interstitial fluid, are extensively disrupted during the surgery. Although the mechanisms that lead to the postoperative development of the syndrome are not fully understood, the vigorous systemic inflammatory response that accompanies the operation may play an important role. This extensive mediastinal dissection may also initiate a generalized systemic inflammatory response.35 Unfortunately, the complication of acute respiratory distress syndrome remains difficult to predict, but all patients should be monitored for abrupt changes in oxygenation in the perioperative period.

Hemodynamics
Patients are given intravenous maintenance fluid (isotonic sodium chloride solution or lactated Ringer solution) at a rate of 100 to 200 mL/h for the first 12 to 16 hours after surgery. These fluids help maintain adequate circulating blood volume to protect vital organs and ensure adequate blood supply to the newly created anastomosis. Major fluid shifts occur in the first few days after surgery, and hypovolemia may be a problem.8 Patients may require fluid boluses in the immediate postoperative period. Crystalloids or blood products may be used to restore circulating volume, but overloading with fluids must be avoided. The lungs are already compromised because lymph clearance has been diminished by the surgical removal of the mediastinal lymphatics and nodes.25 Reduced clearance of lymph predisposes these patients to interstitial pulmonary edema. Malnutrition and low protein levels can further complicate the situation.

These patients require a delicate balance between adequate fluid replacement and fluid overload.8 The extent and duration of the surgical procedure in esophagectomy inevitably results in transudation of fluid into the interstitium. Therefore, patients need volume support and rehydration. However, because they are also susceptible to pulmonary edema, hydration should not be excessive. In most instances, maintenance of 30 mL/h of urine output is evidence of adequate postoperative fluid resuscitation.

Determination of body weight and careful documentation of fluid intake and output should be done daily. Patients usually have an arterial catheter in place. If their hemodynamic status is unstable, they may have a pulmonary artery catheter. Postoperative edema may be significant, depending on the amount of fluid required to maintain hemodynamic stability, so meticulous skin care is necessary. Fluid in the tissues will seek out dependent areas and cause the skin in those areas to be at greater risk for breakdown. When hemodynamic status is stable, patients should be turned at least every 2 hours to assist in maintaining skin integrity. Patients who cannot tolerate frequent turning or who are difficult to mobilize will need a pressure-relieving surface.36

Nasogastric Tubes
In general, all patients have a nasogastric tube after esophagectomy. Do not move, manipulate, or irrigate the nasogastric tube. If the tube comes out for any reason, do not attempt to replace it. The nasogastric tube goes through the anastomosis and is not sutured in place.9,19,22 Attempting to replace the nasogastric tube may result in damage to the anastomosis. Be sure to notify a physician immediately if the tube becomes dislodged or does not appear to be functioning properly.25 Monitor the tube for patency and assess the drainage for color and amount.

Gastrointestinal Care
After esophagectomy, patients are restricted from taking anything by mouth for 5 to 7 days to prevent an anastomotic leak or fistula formation.25 Patients have nasogastric tubes with low-level continuous or intermittent suction. Oral medications, if ordered, are crushed and put down the nasogastric tube; they are never swallowed. Diligent mouth care improves patients’ comfort and reduces the risk for infection and should be maintained while patients are intubated and throughout the period when they cannot take anything by mouth.

A jejunostomy feeding tube is often placed during surgery and is left clamped until used.37 Flush the tube with 10 to 20 mL of isotonic sodium chloride solution every shift. Jejunostomy site care should be performed on a daily basis. Wash the surrounding skin with a gentle soap, and assess the skin for any signs of irritation or breakdown. Apply a non–petroleum-based protective ointment, and make sure that the tube is well secured. Patients may or may not be started on tube feedings 2 to 3 days after surgery, depending on the surgeon’s preference.38,39 Preoperatively, patients may have been receiving total parenteral nutrition or some other high-energy liquid supplement. If so, total parenteral nutrition may be resumed after surgery.

At 5 to 7 days after surgery, a fluoroscopic swallowing examination with water-soluble contrast material is done to check the anastomosis for leaks before oral intake of anything is allowed.25 If a leak is suspected, an alternative form of nutrition should be started. The physician may choose to start tube feedings via the jejunostomy tube or to start patients on total parenteral nutrition. If no leak is detected, patients are started on a clear liquid diet and advanced to soft foods as tolerated.3

Patients should be instructed to eat 6 to 8 small frequent meals each day, because large meals may not be well tolerated.3 Also, instruct patients to avoid very hot or cold beverages and spicy foods. Protein supplements, high-energy foods, or a soft dysphagia diet may be indicated. A dietician is usually involved in patients’ care, and laboratory results from a weekly nutritional panel can guide nutritional decision making. Having patients sit upright, chew slowly, and eat more than 3 hours before bedtime assists in reducing reflux.

Having patients drink fluids between meals rather than with meals assists in controlling signs and symptoms of the dumping syndrome, which may arise in patients who have had their vagus nerves divided. This common adverse effect after vagotomy is related to unregulated gastric emptying and rapid delivery of carbohydrates and partially digested food products into the small intestine. Minimizing liquids with meals and the consumption of frequent, small, low-carbohydrate meals also assists in controlling these signs and symptoms.3

Patients whose oral intake is not adequate by the time of discharge may be discharged with plans for supplemental tube feeding. Such feeding requires that patients or caregivers be taught how to administer tube feedings, and the correct supplies must be ordered and given to the patients before discharge.

Genitourinary Care
Patients have Foley catheters draining to gravity after esophagectomy. Monitor fluid intake and output hourly during the initial postoperative period. Call a physician if urine output is less than 30 mL/h for 2 consecutive hours. Discontinue the catheter as soon as possible to avoid urinary tract infections.

Incision Care
Keep all dressings clean, dry, and intact. The surgical dressing is removed by a surgeon on postoperative day 2. Patients may have a neck incision, which can be opened by a surgeon at the bedside if an anastomotic leak is suspected. Neck incisions that are opened up require wet to dry dressing changes 2 to 3 times a day for several weeks, unless otherwise specified by the physician. In instances in which the anastomosis has separated, patients often have saliva leaking out through the cervical incision. Such leakage is often low in volume and can be managed by simple dressing changes to the neck wound. However, if a patient is leaking saliva in large volumes (>250 mL every 8 hours), application of a wound drainage bag to the lower part of the neck incision may be required. The leak is allowed to seal on its own, but sealing could take several weeks.

Drains
Patients may have a Jackson-Pratt drain to bulb suction coming out of one of the incisions. Monitor the amount and color of drainage each shift. If the bulb drain will not hold suction, notify the medical team. A Penrose drain also may be in the neck incision. Change the dressing for the Penrose drain as often as necessary to protect and maintain skin integrity around the drain.

Infection Risk
Patients who have esophagectomy have many potential sites of infection. They often have compromised nutritional status, they have invasive catheters in the early postoperative period, and they have the usual risk of infection at the surgical sites. Meticulous wound and skin care, hand washing, avoidance of cross-contamination with organisms from other patients, and changing of invasive catheters per the facility’s protocol assist in reducing the chance of infection. Judicious use of antibiotics and adequate nutrition also help avoid infection.

Prophylaxis of Deep Vein Thrombosis
Heparin shots are given subcutaneously twice a day and compression stockings are applied to both lower extremities to prevent deep vein thrombosis. Until patients are ambulating independently, they should keep the stockings on when in bed. Encourage early ambulation as well as leg and ankle exercises. Early mobilization of patients includes getting them out of bed to a chair the first postoperative day and 3 times each day thereafter.

Psychosocial Aspects
Diagnosis of esophageal cancer can be a devastating event in a person’s life. Patients may struggle with depression, mortality, and fear pre-operatively, and most likely they will experience some fear and anxiety after surgery. Patients need support and reassurance postoperatively. They may fear mortality, have concerns about body image, or have feelings of guilt that their lifestyle habits (eg, smoking and drinking) may have contributed to the development of their disease.4 Encourage them to find a counselor with whom they can work through these issues. In addition, some patients may drool; causing embarrassment and adding to their feelings of isolation. These patients need assistance in learning methods to manage their secretions, such as using a portable suction device, discreet use of tissues, and proper disposal of potentially infectious material.4

Offer explanations and support to patients’ family members and friends to promote healthy interactions with the patients. Encourage patients to express their feelings and fears in a safe environment. Consider your own filters or issues with their disease and possible causative factors. Help patients focus on the future and set goals for a healthier diet and lifestyle. Offer community resources when available (see list in "Discharge Instructions").

Other Considerations
A high proportion of patients who have esophageal surgery have a history of heavy smoking and alcohol use. Be aware of possible delirium tremens on postoperative day 3 or 72 hours after the patient’s last drink. Early identification (pre-operative) of patients at risk for signs and symptoms of withdrawal is the best prevention, and early treatment is safest for both patients and staff members. Benzodiazepines (most commonly lorazepam) are ordered to manage alcohol withdrawal. For patients experiencing nicotine withdrawal, consider a nicotine patch.

Postoperative Complications
Esophageal resection is an involved operation with multiple potential complications, of which the nursing staff and the physicians should be aware. The postoperative mortality rate associated with esophagectomy procedures ranges from 5% to 13%. The most common causes of morbidity and mortality are cardiopulmonary complications. Table 4Go lists possible postoperative complications of esophagectomy, their signs and symptoms, and management techniques. Prevention and early detection are the keys to successful management of postoperative complications.


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  		Table 4 Postoperative complications of esophagectomy*

 
Esophageal anastomotic leakage is the most serious postoperative complication and may occur 2 to 10 days after surgery.3


   Discharge Instructions
Top
 Etiology
 Clinical Findings
 Prognosis
 Surgical Management
 Nursing Care of Patients...
 Discharge Instructions
Conclusion
 References
 
Discharge instructions for patients and their families or caregivers should include the following:

The American Cancer Society, survival support groups, social workers, chaplains, counselors, and smoking (nicotine) cessation programs may be helpful.8


   Conclusion
Top
 Etiology
 Clinical Findings
 Prognosis
 Surgical Management
 Nursing Care of Patients...
 Discharge Instructions
 Conclusion
References
 
Esophageal cancer remains difficult to treat. Patients who undergo esophagectomy experience decreased morbidity and mortality with more comprehensive nursing care. This article provides a basis for nurses to better understand esophageal cancer and the perioperative management of risks and complications of esophageal surgery.


   References
Top
 Etiology
 Clinical Findings
 Prognosis
 Surgical Management
 Nursing Care of Patients...
 Discharge Instructions
 Conclusion
 References
 

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  3. Quinn KL, Reedy A. Esophageal cancer: therapeutic approaches and nursing care. Semin Oncol Nurs. 1999;15:17–25.[Medline]
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  10. Billingsley KG, Maynard C, Schwartz DL, Dominitz JA. The use of trimodality therapy for the treatment of operable esophageal carcinoma in the veteran population. Cancer. 2001;92:1272–1279.[Medline]
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  13. Urba SG, Orringer MB, Turrisi A, Iannettoni M, Forastiere A, Strawderman M. Randomized trial of preoperative chemoradiation versus surgery alone in patients with locoregional esophageal carcinoma. J Clin Oncol. 2001;19:305–313.[Abstract/Free Full Text]
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  17. Avendano CE, Flume PA, Silvestri GA, King LB, Reed CE. Pulmonary complications after esophagectomy. Ann Thorac Surg. 2002;73:922–926.[Abstract/Free Full Text]
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