Gastroenterology - Having Oesophageal Surgery

This leaflet has five aims:

• To help you and your family become better informed and more involved in your care
• To explain the operation, you will be having
• To explain about early recovery after surgery (ERAS)
• To describe what will happen after the operation
• To help overcome any worries you may have about the operation

What is the oesophagus?

It is sometimes known as the gullet. It is a long muscular tube through which food travels from your mouth to your stomach after swallowing. The food is passed down the oesophagus by muscular movements.

What is an oesophagectomy?

It is the removal of part or the entire oesophagus (gullet). Depending on where the tumour is it may also be necessary to remove part of the stomach. After the affected part has been removed the two remaining ends are then joined, usually by bringing the remaining stomach up into the chest. This operation may be carried out as an open procedure or as keyhole (laparoscopic) surgery.
 

The picture below shows before and after an oesophagectomy

Why do I need an operation?

You have recently been diagnosed as having cancer of the oesophagus. This usually causes a blockage and makes it difficult for you to swallow. You have had many investigations and the results of these tests have shown that an operation is possible to remove the tumour that is blocking your oesophagus. The operation is performed to remove the cancer in your oesophagus that will enable you to eat and drink better. It is hoped that the procedure will be curative.

Will I need any other treatment if I have surgery?

Sometimes patients are offered a course of chemotherapy before and after the operation to help treat the cancer.

How is the operation performed?

The surgery is done in two stages at the same operation. An incision is made in the abdomen so that the stomach can be freed from the surrounding tissues, this will either be performed by open surgery or keyhole surgery. This allows it to be pulled up into the chest.

A second incision is made in the chest between two ribs to allow the surgeon to see the upper part of the oesophagus, this will either be performed by open surgery or keyhole surgery. One lung is deflated to allow a better view. Most of the oesophagus is removed. The stomach is then attached to the upper end of the oesophagus, high up in the chest or sometimes the neck. The chest and abdomen are sewn back up.

How long will the operation take?

The operation will take about six hours.

Enhanced Recovery after Surgery (ERAS)

The Upper GI team follow a programme of care to promote early recovery after surgery. The programme has input from a whole team (surgeons, anesthetist, specialist nurses, physiotherapists and dietitians). Its aim is for you to recover from your operation as soon as possible.

What will happen after the operation?

The first 24-48 hours will be spent in the Intensive Care Unit. Here you will be closely monitored. When you are stable you will be transferred to the Surgical High Dependency Unit. You will stay here until you are well enough to go back to the ward.

You will have several tubes attached to you when you come out of theatre.

These will include:

• Epidural for pain relief
• Intravenous Infusion (a drip) to give you fluid and prevent dehydration
• Jejunostomy tube - the surgeon will place this tube during the operation. It goes directly into your small bowel, further downstream than the site of your operation and enables liquid feed to be trickled into the bowel, so that you can receive plenty of nutrition even though you will not have started eating yet. We will send you home with the jejunostomy tube and feed for a short period. The need for this tube will be assessed at your clinic follow up appointments.
• Chest drains - this drains any fluid that may collect in the chest after the operation. It also allows the lung to re-inflate
• Urinary catheter - this tube is in your bladder. Urine drains via the tube so that it can be measured accurately. It is removed when you are fully mobile
• Naso-gastric tube - this tube goes up your nose, down the back of your throat and the tip sits near to the site of your operation. The tube is placed to help stop nausea and vomiting. It is removed a few days after the operation
• Oxygen - you will be given oxygen via a mask to help you breathe
• Wound drains - these are tubes that drain any blood of fluid from inside the abdomen after the operation. They are removed after a few days following your operation

How will my pain be controlled after the operation?

One of the important parts of this ERAS programme is good pain control, which will help you to be up and about as soon as possible (early mobilisation). Your pain will be controlled by an epidural. This is a fine tube placed in your back, through which pain numbing medicines are given. This is usually kept in for several days and removed painlessly.

Mobilisation/Physiotherapy

Early mobilisation (i.e. getting out of bed and walking around) is a very important part of your recovery. Most patients will get up the day of, or the day after their operation. You will be encouraged to sit out in a chair and walk short distances at least 4-5 times a day, with help from the nursing staff, physiotherapists and specialist therapy assistants.

Having an operation has an effect on your breathing and your circulation. The physiotherapist will see you and will be able to give you help and advice. The following exercises will help to reduce complications and speed your recovery.

Incentive Spirometer

You will be given an incentive spirometer to use. This is a small device that encourages you to take deep breaths by inhaling through a tube. It is important to use this before surgery (at home) and after surgery. You will be given a separate information sheet on how to use this.

Deep breathing exercises

Following your operation, you tend to breathe more shallowly and not expand your lungs at the bottom. These exercises help to improve your lung movement and clear phlegm off your chest.

Start these exercises as soon as you wake up, and continue hourly whilst awake, until you are up and about again.

• Sit in a comfortable position with your back well supported (upright in bed or in a chair), place your hand on the upper part of your stomach
• Relax your shoulders
• Take a slow deep breath in through your nose, concentrating on expanding the lower part of your chest
• Hold the breath for a count of 3, then slowly breathe out completely
• Repeat 3 or 4 times

Huffing

Coughing can be uncomfortable and tiring. It has been found that ‘huffing’ helps to move phlegm in preparation for coughing

• Take a small breath in
• Open your mouth wide and squeeze the air forcefully out of your lungs as quickly as possible (as if steaming up a mirror)
• Your stomach muscles should contract but your throat muscles should not tighten
• The huff must be long enough to move phlegm from the airways

Coughing

Adequate pain relief and the correct coughing technique are essential to clear phlegm comfortably and effectively. Once phlegm has been loosened by ‘huffing’ try a supported cough.

• Position yourself either sitting in a chair, on the edge of the bed, or lying-in bed with both knees bent up, to relieve the stretch on your tummy
• Place hands or pillow over your stomach
• Take a deep breath in and as you cough squeeze your hands in over your stomach in order to support it

Circulatory exercises

Good circulation in your legs helps to prevent deep vein thrombosis (DVT) or blood clots. You will be given a pair of special support stockings (TED stockings) to wear the morning you go to theatre. You will be encouraged to wear them throughout your hospital stay. These help to push blood back to your heart. Also remember not to cross your legs or ankles as this can make the circulation more sluggish.

• Ankle circling involves moving the feet clockwise and anti- clockwise in circles. Repeat 10 times
• Keeping your legs straight bend your feet firmly up and down at the ankles. Repeat 10 times
• Keeping your legs outstretched, press the back of your knees down into the bed and tighten your thigh muscles. Hold for a count of 3 and relax. Repeat 10 times

It would be helpful to practice these exercises before you come into hsopital.

When will I be able to eat and drink after the operation?

You will not be able to eat or drink for five days after the operation to allow things to heal inside, this is known as being nil by mouth. You will be given special liquid feed using a pump via a feeding tube in your abdomen or fed through a vein.

After five days of being nil by mouth, you will then be able to start taking sips of water, and if there are no problems, build slowly up to free fluids and then soft diet. A dietician will monitor your food intake and offer advice regarding dietary supplements.

Will I be able to eat normally in the future?

Yes, your stomach is used to make a new gullet like tube and joined to the remainder of the oesophagus so that you will be able to swallow normally. The key to eating after this operation is little and often.

Eating after an oesophagectomy does take some adjustment, especially for the first few months. The dietician and medical staff will be available for advice and support.

How long will I be in hospital?

You can expect to be in hospital for about 10-14 days if there are no complications.

Are there any complications attached to this surgery?

Complications can occur after any surgical procedure. A gastrectomy is a major operation. The main complications are:

• Chest infection. This is usually due to not being able to cough and breathe deeply because of the cut on your chest and abdomen. The physiotherapist and nurses will encourage breathing exercises to prevent this and ensure that you have effective pain relief to carry them out. You will also be encouraged to give up smoking before the operation
• Cardiac problems. Some patients may already have heart problems, which may be exacerbated by surgery. Having a major operation can put stress on the heart
• Anastomotic leak (a leak from the site where the bowel is joined to the gullet). With any new join in the gut, there is a small chance that there will be a leak. To minimise this, the gut is kept empty by use of a drainage tube called a nasogastric tube. If a leak does occur, it may be necessary to re-operate to control the leak. This would mean opening the chest up again and going to intensive care afterwards. Sometimes minor leaks can be managed without any further surgery. In this case you would be kept nil by mouth and would be fed by jejenostomy or a special liquid feed straight into your veins called TPN
• Wound infection. Sometimes the wound gets locally infected and may need treating with antibiotic
• Deep Vein Thrombosis. You will be given a special pair of white elastic stockings to wear and a small injection once a day. These will help prevent clots from forming in your legs often caused by reduced mobility. You will continue on these injections for 28 days after your operation
• Bleeding. This may occur during or after the operation. Very occasionally it may be necessary to do a further operation to stop the bleeding. If a significant amount of blood is lost, you may require a transfusion

Will I need further treatment?

Once you have had the operation you may need a course of chemotherapy.

You will also be prescribed a 28-day course of blood thinning injections, these are given to prevent you from getting a blood clot. These are given from day 1 of your surgery and you will complete the remainder of the 28-day course at home. You will be shown how to administer these yourself whilst in hospital.

What if I decide not to go ahead with the operation?

Your decision will be respected, and your doctor will discuss alternative treatments with you. These treatments would be unlikely to cure the cancer and would be palliative.

Life after oesophageal surgery

This part of the leaflet is to help answer any questions you may have when you are discharged from hospital.

Will I need to rest when I go home?

You have had a major operation that has resulted in a long stay in hospital. Recovery from this type of surgery is not fast and it may be several months before you return to your normal activities of living. You may feel that life can never be the same again, but with slight modifications it can be a very good life.

You must now learn to live with the changes in your system so that they affect your quality of life as little as possible.

Will I be able to swallow normally?

Yes, you should have no trouble in swallowing normal food after the operation.

If you experience difficulty with swallowing when you are at home, you should contact the Upper G.I. Specialist Nurse or your
G.P. for advice.

Will I have problems eating after the operation?

• You may find you need to eat smaller amounts more frequently i.e. little and often
• The dietician may recommend that you have some nutritious drinks after surgery
• Chew food well and relax after meals
• Sit upright when eating
• Initially it is advisable to eat slowly and have small portions until you know your own capacity
• If you do eat too much at one sitting you may feel uncomfortable, this will ease with resting, usually within 30 minutes
• It is advisable not to have a drink with your meal as the fluid may fill you up and make you feel bloated. You should take fluids approximately one hour before or one hour after eating
• If you experience continued bloating and nausea after eating, it may be that your stomach is not emptying as well as it did before your operation. If this occurs, you should contact the Specialist Nurse or your GP who can give you advice and prescribe medication to help your symptoms if necessary

What will I be able to eat after the operation when I’m at home?

You should be able to eat a relatively normal but soft diet by the time you leave hospital.

What should I do if I have problems with my appetite?

• Eat small portions of food frequently
• Try to have high calorie foods
• Stick to foods you like
• Try to have nutritious drinks such as milk shakes and milky coffee
• Use supplement drinks prescribed by the dietician. There are a variety of these supplements available and you should choose the one which suites you best
• If lack of appetite persists and you are losing weight, contact the specialist nurse or your GP

How can I gain weight?

• The hospital dietician will give you advice before you go home
• It will be quite normal for you to lose a little weight when you first go home
• Try to have snacks in-between meals such as biscuits, chocolate, crisps, milky drinks, yoghurts
• Eat butter not low calorie spread
• Try to have at least one pint of full cream milk daily
• Add milk, butter, cream cheese to foods such as mashed potatoes, soups and vegetables and extra cream, sugar and jam to foods such as puddings and cereals
• Use supplement drinks e.g. Build-up or Complan

Will I be able to drink alcohol?

You can drink alcohol as long as it does not interfere with any of your medications.

When will I be able to start exercising when I go home?

You should be able to start light exercise as soon as you get home. Short walks or a little light housework should be possible within a few weeks. Progress may be frustratingly slow, and you should not push yourself to do too much in the early stages. As time progresses and you feel you have more energy, increase the exercise as you feel able.

It is also beneficial to continue with the breathing exercises you were taught by the physio in hospital. This may help prevent chest problems once you are discharged.

Will I have any problems with acid reflux or regurgitation of food?

You may experience some problems especially when bending or stooping forward. This can be avoided by kneeling or squatting. If you suffer from reflux when sleeping or resting, it may help to lie on your left side and avoid the right. Medication can also be prescribed to control the symptoms.

Will I have pain when I go home?

Most patients will have little or no pain a few weeks after their operation. If you do have any pain it will be assessed before you leave the hospital and appropriate painkillers will be prescribed for you to take home.

You may experience some discomfort in your right chest where the scar from your operation is when you carry out certain exercises or manoeuvres.

You may also have limited mobility of your right arm initially after the operation but with regular exercise this should return.

Will my voice change after the operation?

There is a possibility that you may have some hoarseness of your voice after the operation. This may occur due to injury to the vocal cords.

Will I be followed up at the hospital after the operation?

Yes, you will be seen in the outpatient department approximately two weeks after discharge and then at regular intervals from then on.

Will I have any support when I go home?

Support will be available to you on discharge. You will be assessed by individual members of the team before you leave hospital to see if you need help and support when you go home.

The team includes:

• Medical staff
• Specialist Nurses
• Ward nursing staff
• Dietitians
• Physiotherapist

Any care you need will be provided and arranged before you leave hospital. If needed the team can arrange for you to be seen by the social worker and occupational therapist.

Is there a support group for patients who have had oesophagectomy?

Yes, Salford Royal Hospital has a patient support group that is run every 2 months, ask your specialist nurse for further information about this.

For further advice or information please contact:

Upper GI Specialist Nurse - 0161 206 5062
Email: uppergi.nursingteam@nca.nhs.uk

Upper GI Surgical Secretaries
0161 206 5472
0161 206 5448
0161 206 5128