What is the esophagus?
The esophagus is a 23-25cm muscular tube connecting the throat to the stomach. The wall of the esophagus is composed of muscular layers which move in wave like contractions to push food into the stomach. The esophagus is lined with a mucous membrane similar to the lining of the mouth.
A tumor is the abnormal growth of cells in the body. These cells can be either benign (not cancerous) or malignant (cancerous). There are two common types of esophageal cancer arising from the lining (mucosa) of the esophagus: Squamous cell carcinoma and Adenocarcinoma. Squamous cell carcinoma usually develops in the lining of the upper two thirds of the esophagus. Most of the length of the esophagus is lined with squamous cells. In contrast, Adenocarcinoma is found mainly in the bottom portion of the esophagus where the esophagus and stomach meet.
Risk Factors for Esophageal Cancer
- Age: Incidence increased with age
- Gender: Men have a three-fold greater rate than women
- GERD: Esophageal reflux disease
- Barrett’s Esophagus: Pre-malignant changes of the esophageal lining secondary to prolonged acid reflux
- Tobacco Use
- Alcohol: Heavy alcohol use is a major risk factor
- Irritation/Injury to the Esophagus: Caustic ingestion, achalasia
- History of Head and Neck Cancer
Symptoms of Esophageal Cancer
In the initial stages of esophageal cancer, before the tumor obstructs part of the esophagus, there are no warning signs or symptoms. Typically, the first noticeable symptoms are difficulty swallowing (dysphagia) or the feeling that food gets “stuck” when swallowing. These symptoms become apparent when there is increased growth of the tumor inside the esophagus partially obstructing the lumen. With increasing obstruction, swallowing liquids also becomes impaired. Other symptoms may include weight loss, pain with swallowing (odynophagia), regurgitation, and bleeding by mouth or rectum.
Testing and Treatment
Staging – Staging of the disease is used to determine how early or advanced the cancer is and whether it has spread to other parts of the body. The stage of the cancer will then determine which therapy is best for you. In the case of esophageal cancer, treatment could include medical therapy (chemotherapy and radiation therapy) alone, surgical resection, or a combination of medical therapy couples with surgical resection is typically done with CT, EUS, and PET Scans.
CT Scan – A CT scan of the chest and abdomen gives the surgeon information about the lungs, mediastinum and lymph nodes surrounding the esophagus as well as other parts of the body including the liver, stomach and adrenal glands.
Endoscopic Ultrasound (EUS) – Once a diagnosis of cancer is made, the main tumor and adjacent lymph nodes are evaluated using endoscopic ultrasonography or EUS. This is an outpatient endoscopic test that utilizes a special scope that emits ultrasound waves to produce a picture of the tumor and surrounding lymph nodes. Your thoracic surgeon will discuss with you which course of treatment is best based on many factors including the size of the tumor, involvement of surrounding tissue and lymph nodes, presence or absence of metastasis, and your overall health/physical condition.
PET Scan – Positron Emission Tomography scan is a special scan used to define in more detail the extent to the cancer. The PET scan uses radioactive glucose injected into the body to determine the metabolic function of cells. Malignant cells that are rapidly dividing use large amounts of glucose. The malignant cells will enhance or light up on the PET scan which will allow the physician to determine if the esophageal cancer has spread (metastasized) to other parts of the body.
Chemotherapy/Radiation Therapy – Medical therapies consisting of chemotherapy and radiation therapy are sometimes used before surgery to shrink the tumor and decrease the chance of recurrence after surgery. If indicated, the oncologist and radiation oncologist will discuss the type and duration of therapy with you. Approximately 4 to 6 weeks after completion of chemotherapy and radiation therapy, repeat staging studies (which may include CT scan, EUS and PET scan) will be performed to evaluate the effectiveness of the medical therapy and to determine if surgery is still indicated. If surgery is indicated, a surgery date will then be set after all preop tests are completed and you are deemed medically ready for surgery.
Surgical Treatment – Esophagectomy is the surgical removal of most of the esophagus and surrounding lymph nodes. The stomach or colon (large bowel) is then brought up and attached to the remaining portion of the esophagus to restore the anatomy and allow swallowing. The goal of surgery is to remove the tumor as well as a margin of cancer free tissue around the tumor. There are two commonly used surgical approaches; transhiatal and transthoracic. The transhiatal approach involves a neck and abdominal incision. The thoracic cavity is not opened. In contrast, the transthoracic approach involves an incision in the abdomen and a separate incision in either the right or left chest. The choice of operation depends on the location of the tumor and the surgeon’s preference.
Preparing for Surgery
Preoperative Evaluation – This will include all testing to ensure that you are physically able to undergo surgery. If your testing is done at an outside facility other than Penrose Hospital, it is your responsibility to have any outside records sent or faxed to the Thoracic Surgery Clinic at 719-473-3553.
Blood Tests – Complete white Blood Cell Count (CBC), Chemistry, Coagulation studies (PT/ INR), type and screen, and occasionally type and cross.
What you can do to prepare for surgery – Maintain a high level of activity. Walk as much as possible. Eat a well balanced diet. If you are having difficulty swallowing, you may need a nutritional supplement to maintain your weight.
You will be provided with instructions for bowel prep which is to begin 1 to 3 days before surgery.
Stop or limit consumption of alcohol. If you do drink on a regular basis, please make us aware.
Stop blood thinners, such as Coumadin, Warfarin, Lovenox, Plavix and Aggrenox. As well as pain relievers, such as aspirin and aspirin containing products including Aleve and Ibuprofen seven days prior to surgery. If you are taking any of these medications for a stroke or blood clot, the timing of when to stop these will be discussed.
If there are any changes in your condition the week prior to surgery, please call our office at 719-776-7600.
Nasogastric Tube – A nasogastric tube (NG tube) is a small tube inserted through your nose, down the esophagus and into the stomach while you are asleep in the operating room. This tube helps to insure that the stomach doesn’t become too distended which may compromise blood supply to the remodeled stomach. The NG tube will remain in place for 3 to 5 days.
Pain Management – Before surgery begins, you will have an epidural catheter placed in between two vertebrae in your back by an anesthesiologist. Epidurals are commonly used for postoperative pain management. The epidural catheter is a thin, plastic catheter which will be connected to a computerized pump to dispense medication directly in to your epidural space next to the nerve roots. There are two types of medication in the epidural pump: Opioids (narcotics) and local anesthetics (local nerve numbing). Epidural analgesia gives excellent pain relief and has been shown to cause less drowsiness than IV medication. The epidural analgesia works by stopping pain early and blocking its path to the brain.
You will have the epidural for 2 -4 days post surgery. During this time, it is important to get out of bed, sit in a chair and walk in the room or hallway. It is also important for you to be able to cough, take deep breaths and use the incentive spirometer. The incentive spirometer measures how much your lungs are filling with each breath and helps to keep the small air sacs, deep in your lungs, fully expanded. This will help to avoid post surgical complications such as pneumonia and lung collapse.
After the epidural is removed, you will be placed on an oral pain medication alone or in combination with an IV pain medication for severe pain. We will titrate these medications so that you are comfortable and able to continue with your daily activities. By the time you are ready for discharge, your pain will be controlled by oral pain medications only, either taken by mouth or through the feeding tube. When you are discharged, you will receive a pain management plan. During the first few weeks, you may find it necessary to continue taking pain medication fairly regularly. As the pain begins to diminish, you may way to switch to milder pain medications such as Tylenol (Acetaminophen) or Motrin (Ibuprofen) as instructed by your surgeon.
Incisions – During surgery, you will have one or more chest tubes and drains placed to help remove fluid from your chest or neck. These incisions, along with the surgical incision, will be monitored by the health care team. Please keep your incisions clean and dry. It is normal for your incisions to have a little redness. Once discharged, your surgeon may inform you to keep your incisions uncovered. If the incision is draining, please cover with a small dressing. The sutures and/or staples will be removed on your first post surgical office visit.
Activity – After surgery, it is important for you to get out of bed every day. It is recommended that you sit in the chair at least three times per day and walk in the hallway as tolerated. As you recover, you will be able to increase your level of activity. You may alternate activity periods with rest periods. Once discharged, you should continue to increase your activity and walk as much as possible. It is okay to walk outside and climb stairs. You should avoid strenuous exercises for the first 4 to 6 weeks.
You may ride in a car, but not begin driving until after your first post-op visit and as long as you are not taking narcotic pain medication.
You may shower when you get home and wash the incision with soap and water. Do not soak the incision in the bathtub.
Bowel Regimen – Narcotic pain medication (Percocet, Norco, Oxycontin, Dilaudid, Lortab elixir) can cause constipation. You will be on a bowel regimen in the hospital. This bowel regimen will consist of stool softeners, laxatives or bulk forming agents. Once discharged, we recommend that you continue some form of bowel regimen at home as long as you remain on narcotic pain medication.
Postoperative Barium Swallow – X-ray of the esophagus performed while drinking barium 4 to 7 days after surgery which will demonstrate any abnormalities at the connection of the esophagus in the neck or the chest. If there are no abnormalities in the newly formed esophagus at the connection site, we will begin to slowly advance your diet.
Diet after Esophagectomy
J-Tube (Jejunostomy Tube) – A feeding tube will be placed in to your small intestine either before surgery or during surgery to be used when you are not able to eat anything by mouth. This tube will feed you and keep you in optimal condition after surgery until your oral diet provides enough calories on a daily basis. You will not be able to have any oral intake for at least 5 days after surgery. Once your surgeon decides you are stable enough to begin an oral diet, you will start on a clear liquid diet (see clear liquid diet below). You will be sent home on an oral diet and often with supplemental tube feeds, as well. Diet/ Nutritional information will be discussed with you prior to your discharge. The J-tube is a temporary nutritional aid and will be removed 1-2 months after surgery once your surgeon decides you are eating enough to maintain good physical health.
Oral Diet – You will have several types of oral diets after your surgery. Your diet will change based on how well you can tolerate food and how well you are recovering.
Clear Liquid Diet – Once your surgeon has determined that you may begin to eat, you will start with a clear liquid diet. A clear liquid diet consists of:
- Clear juices
- Clear broth
- Coffee and tea
Full Liquid Diet – If you are tolerating a clear liquid diet, your surgeon may advance you to a full liquid diet. A full liquid diet consists of all of the above liquids and the following:
- Yogurt without fruit
- Oatmeal or Cream of Wheat cereal
- Ice Cream
- Strained cream soups
- Milk, pudding, sherbet, nutritional supplements (Ensure or Boost)
Soft Diet – After tolerating a full liquid diet, you will advance to a soft diet. A soft diet consists of bland, soft foods and beverages:
- Cooked eggs, omelets
- Pancakes, French Toast, Cooked Cereals (avoid coarse cereals)
- Any canned or cook ed fruits (avoid fresh and dried fruits)
- Finely ground lean beef, lamb, pork, veal that is prepared any way except fried (avoid tough meats, fatty meats or spicy meats)
- Mild cheeses, smooth peanut butter
- Soft candy without nuts/fruits, sugar, syrup
- Cooked vegetables without seeds such as asparagus, carrots, beets, green beans
- Condiments such as mustard, ketchup, salad dressings (avoid nuts, seeds, pickles)
Foods to initially avoid:
You may add them back to your diet once you are eating regular food, which is usually after your first post-op visit. Start with small portions.
- Bread, crackers with nuts/seeds or dried fruit, sweet rolls
- Coarse cereals, cereals with fresh or dried fruit
- Carbonated sodas, alcohol, citrus juices
- Fried foods, fried eggs
- Highly seasoned foods
- All fresh and dried fruits, fruits with seeds or skin, all citrus fruits
- Chili or other spicy soups
- Crunchy peanut butter
- Any candy that contains nuts, seeds, fresh or dried fruits, coconut
- Raw vegetables, tomatoes, tomato juice, tomato sauce, vegetable juice
- Gas producing vegetables such as broccoli, brussel sprouts, cabbage, cauliflower, corn, green peppers
- Dried beans, peas, pickles, olives
Dumping Syndrome – Occurs when food from the stomach moves in to the small intestine abnormally rapidly. This accelerated process is often related to changes in your stomach associated with surgery. Signs and symptoms include nausea, vomiting, abdominal pain, cramps, sweating, and diarrhea. Dumping syndrome is usually self limiting. The following tips will help you to avoid and/or relieve the symptoms of dumping syndrome.
- Eat small, frequent meals 5-6 times per day. Eat slowly and chew food completely before swallowing.
- Do not drink liquids with meals. Drink liquids 30 minutes to one hour after eating.
- Consume more protein and fiber in your diet. Avoid high sugar foods in the immediate post surgical period. You can gradually reintroduce these foods into your diet one or two months after surgery.
Please weigh yourself daily – We will be following your weight closely at each office visit. Please inform us of any drastic changes in your weight between office visits.
Dilation – In some instances after surgery, scar tissue forms around the connection of the newly formed esophagus with the remaining portion of the old esophagus either in the chest or the neck. This scar tissue may cause the new esophagus to be narrowed which may result in difficulty swallowing (dysphagia) or the feeling that food gets caught. A dilation may be necessary to stretch the esophagus so that food may pass more easily. A dilation is an endoscopic procedure which is done as outpatient.
The final result of your pathology will be discussed with you either prior to discharge if the results are complete or during your first post surgical clinic visit. If there is need for further treatment, arrangements will be made for you to see an oncologist. At the time of discharge, you will be given a follow up clinic appointment which will be one or two weeks after leaving the hospital. Any remaining staples or sutures will be removed during this visit. We will also evaluate your overall well being and nutritional status. If you need to change your appointment for any reason please call 719-776-7600.