ESOPHAGECTOMIES The following information has been retrieved from the Esophagectomy Toolkit that was developed by the nurses in CrCU – Esophagectomy Working Group.

Surgical Management To understand how to manage a patient with an esophagectomy, it is important to understand the complex surgical process that a patient has to go through. What transpires with an esophagectomy is the surgical removal of part or the entire , the uppermost part of the , and all of the surrounding lymph nodes. The stomach is then pulled up through the chest wall to make a new esophagus (Stanford School of Medicine, 2015). The thoracic surgeons at Lakeridge Health – Dr. Marcus, Dr. Trainor, and Dr. Dickie, perform the Ivor Lewis Surgical Procedure. This procedure is where the esophageal tumor is removed through an abdominal incision and a right thoracotomy. The esophagogastric anastomosis (reconnection between the stomach and remaining esophagus) is located in the upper chest (Stanford School of Medicine, 2015).

Anatomy and Physiology

The vagus nerve travels along the esophagus and serves the stomach. The function of the vagus nerve is to trigger the pylorus muscle to tighten, which will hold food in the stomach when eaten. This allows the stomach to break down fats and sugars. After approximately two hours, the vagus nerve stimulates the pylorus muscle to relax so that the broken down food can be released into the (Tewfik & Meyers, 2013). Due to an esophagectomy, this nerve is removed, and the pylorus muscle is cut to allow for easier passage of food from the stomach into the small bowel. Because of all of these changes, the body will no longer be able to digest fats and sugars in the same manner in which it had before (Society of Thoracic Surgeons, 2014). Another change that happens when a patient undergoes an esophagectomy revolves around the blood supply to the stomach. As a result of the upper part of the stomach being removed, several arteries that normally supply blood are ligated or dissected during the procedure. One artery, right gastroepiploic artery, is left after the procedure (Reed, 2009).

CrCU Post Esophagectomy Patient Assessment/Care All complications are to be reported to the Intensivist AND Surgeon for follow up orders. Complication Signs and Symptoms Preventative Strategies Assessment Management Pulmonary Complications Fever, tachypnea, Deep Breathing and Vital signs and O2 sat Reintubate only if required – can occur in **16 to diminished breath sounds, Coughing q 2-4 h q1h/temp q4h Antibiotic therapy 67% of patients and cause hypoxemia which can lead Incentive spirometry as ABGs as ordered NOT to use continuous two-thirds of postoperative to confusion, CXR results ordered CXRs as ordered or bilevel positive airway esophagectomy mortality showing infiltrates, Turning q2h /mobility as Respiratory Assessment pressure as it could cause dyspnea/ shortness of ordered q4h/prn an anastomotic leak or Pneumonia, ARDS, breath Elevate Head of Bed 45 dehiscence COPD, bronchospasm, Degrees atelectasis Chest physiotherapy Mouth Care q4h & prn - Diligent mouth care improves patient’s comfort and decrease potential for infection ( ie. Sage Kit use – no swallowing ) Anastomosis Leak – Can Fever, inflammation at site, NPO – NO Ice Chips, to Chest Tube as per Barium Swallow to assess occur in **5 to 18% and abdominal pain or from prevent anastomosis leak protocol - Monitor changes for leak can increase mortality up shoulder area, drainage or fistula formation in amount, color and Potential for CT with to 12% from wound or around site, consistency, output of contrast subcutaneous emphysema, Keep head of the bed at 100mls/hr are Drainage of leak by wound Develops due to tension at tachycardia or tachypnea, 45º at all times, avoid Common, drainage from opening or percutaneous anastomosis sites, reduced hypoxemia, change in chest Trendelenburg To promote pleura starts drainage vascularity, long surgical tube drainage color - Bile healing of the anastomosis sanguineous color but Antibiotic therapy time, , or color and prevent aspiration should transition to oral intake before healing serosanguineous. Anastomosis leak is more Manage Pain – epidural Palpate site - Chest tube pronounced when nutrition and/or PCA, if on an sites may develop is started. Stop tube feeds epidural – the subcutaneous emphysema and notify doctor anesthesiologist overrides due to an air leak from any orders for pleural injury, benzodiazepines, New onset of antiemetic, or subcutaneous emphysema analgesic medications may indicate leak from the esophageal anastomosis Hydration – to ensure delivery of oxygen and Epidural as per protocol nutrients to promote Vital signs and O2 sat q1h healing Intake/Output q1h – call MD if urine output less No nasotrachael suctioning than 30mL/ 2 consecutive if intubated to prevent the hours risk of passing a catheter NOTE* if pt is to be through the new intubated and has an anastomosis epidural – the epidural is to be stopped and anesthesiologist notified Chyle Leak – can result White milky drainage from Surgical Technique Monitor chest tube output Stop tube feeds due to an injury to the the chest tube q8h and during J-Tube Measure triglyceride levels lymphatic system and feed initiation of drainage affect **8% of the TPN patients, with a mortality Fluid Resuscitation rate as high as 50% If output 400-600 mL q8h continuously for 2-3 days, surgical intervention required Gastric Necrosis – Fever, oliguria, acidosis, Surgical Technique Signs of Acidosis diagnosed in *2 – 3 % of tachycardia, hypotension, A Hypotension – decreased Signs of Shock CT with contrast pts. As a result of poor Fib blood supply to the artery Foul chest and NG tube Antibiotic therapy blood flow – high supplying the stomach drainage Surgical Intervention mortality rate compromises graft Vital signs q1h No use of vasopressors perfusion - treat with fluid unless ordered by boluses surgeon

Cardiovascular Chest pain, shortness of Lab values as ordered Cardiology consult Complications breath, irregular heart rate, Hemodynamic stability Electrolyte values and Cardiac medications 1 – Atrial EKG changes Electrolyte balance replacement as ordered (digoxin, diltiazem, b- Fibrillation/SVT/MI Pain Management Cardiovascular blockers) **occurs in 2pprox.. 20% Assessment q4h/prn Cardioversion of the patient population Pain assessment q4h/prn and predisposes pts to EKG as ordered pulmonary complications, anastomotic leaks, increased mortality rates, and may indicate Gastric Ischemia

Difficulty breathing, limb Mobility and leg exercises Cardiovascular VQ scan 2- DVT and/or pulmonary swelling/inflammation/pain, as ordered Assessment q4h/prn Doppler emboli tachypnea, arrhythmias Antiembolism stockings Lab values – Hb, Aptt, Anticoagulant and/or sequential INR medication/infusion compression device Anticoagulants

Nasogastric tube -placed NG accidently DO NOT move, Should hear suction sound NG insertion – by MD during surgery to removed/blocked manipulate, or attempt to through the lumen if only decompress stomach and replace if the tube comes suction is applied and allow better healing of out as there is potential for ensures that the suction sutures the NG tube to go through does not cause the tube to the anastomosis become lodged against the NO medication or feeds wall of the stomach Do not flush/irrigate NG tube unless ordered by surgeon

**NOTE J-Tube - placed during surgery and is left clamped until used, flush the tube every shift if ordered by surgeon, J tube feeding may be started after bowel sounds, and only ordered by surgeon

Logue 2011; ** Raymond 2014; Mackenzie 2004