Esophagectomy to Treat Diseases of the Esophagus

Esophagectomy is a surgical procedure to remove some or all of your esophagus, which is the tube that connects your mouth to your stomach, and through which food passes. A “new” esophagus is constructed using part of another organ, usually the stomach. An esophagectomy may need to be done in cases of esophageal cancer, or to treat noncancerous conditions such as achalasia. After this type of surgery, it often takes a few months for your body to heal and for eating habits to return to normal. You will not be able to eat or drink anything for a while after surgery while your body is healing, but you will have a temporary feeding tube for nutritional support (if you had a feeding tube placed before your surgery, you will likely continue to use the same tube). Your surgical team will likely consist of your surgeon, advanced practice providers (NPs and PAs), fellows and residents, and nurses; your hospital team will also include important team members such as case management, nutritionists, and physical/occupational therapy when needed. Below are some things to expect while preparing for the procedure, during your hospital stay, and after discharge home. 

Before the Procedure

An extensive workup is done prior to an esophagectomy to ensure the best possible outcome. If your surgery is being done for cancer, an endoscopy with biopsies is done to get samples and help determine your treatment plan. You may also need to have surgical biopsies done through small incisions in your abdomen (laparoscopy), and you may need to have a feeding tube placed before starting treatment. Based on these tests, you may need to have chemotherapy and/or radiation before your surgery; if that is the case, imaging studies such as CT and PET scan will need to be repeated before you go to surgery. It is possible that you may also need to have biopsies repeated before proceeding with surgery. If you need an esophagectomy for a noncancerous condition, such as achalasia, you will likely have studies done on your esophagus, as well as a CT scan to review your anatomy for surgical planning. You will also likely have your heart function evaluated to make sure it is strong enough to support you through the surgery. Your team will discuss these results with you in clinic as you prepare for surgery.

If you smoke, you will need to quit prior to surgery as smoking greatly increases the risks of complications after surgery. We can help with this by recommending a cessation program, as well as offering prescriptions for nicotine replacements (nicotine patch, etc.) when appropriate. 

Your team will review medications with you at your preoperative appointment, as well as give you instructions about when to stop eating or hold your tube feeds. 

During the procedure

An esophagectomy (or esophagogastrectomy) is the removal of the esophagus, the top part of the stomach, and surrounding lymph nodes. Often times, the remaining portion of your stomach is used to form a “new” esophagus; occasionally, a part of the intestine may be used instead. This is then pulled up and connected to the healthy portion of your remaining esophagus. There are multiple surgical techniques that may be used to perform an esophagectomy, including open (larger incisions, possibly in neck, chest, and/or abdomen), minimally invasive (smaller incisions in chest and abdomen), or a combination of both. 

After the procedure

Depending on how you tolerate the surgery, you may require a short stay in the ICU if you need some extra care for your heart or lungs. If you did well during surgery and in the post-anesthesia care unit (PACU), you may be able to go straight to the stepdown unit. 

 

 You will not be able to eat or drink anything after surgery to allow for healing, but you will get all the nutrition you need through a feeding tube that    goes into your small bowel. You will also have drain(s) that will allow fluid and/or air to escape, and allows us to evaluate that as a measure of your progress. You will likely have a tube in your nose that goes into your stomach, which helps keep your stomach empty and prevents pressure from building up, which gives the surgical sites time to heal. This will be removed before you go home. You will go home with the feeding tube, and may go home with a drain in place. See below for detailed instructions on caring for your feeding tube. Your home medications may need to be changed as well, which your team will discuss with you prior to discharge.

In the days after surgery, the hospital staff will help you to get out of bed to the chair, walk in the hallways, and will help teach you how to care for your feeding tube and drain at home. Case management will also meet with you to help determine any assistance you may need at home, and will work with you and your insurance company to set that up.

You will be given a clinic follow up appointment for about 2-3 weeks after discharge. Bring your drain log with you to clinic, as well as a list of any questions you may have. If you are doing well at your clinic appointment, you may be allowed to begin taking in some liquids by mouth. You may be told to begin with clear liquids, then advance to full liquids, and then a soft diet. Further diet instructions are noted below. Your team will give you details of what to eat and when to advance your diet. 

 

Diet changes

After surgery, you will not be able to eat anything by mouth.  Once you start eating, your surgeon will advance your diet based on how well you can tolerate food.  In general, you will advance through three types of diets:

• Clear liquid diet

• Full liquid diet

• Soft diet

More information about these diets is given below.

Recovering at home

- You will have a weight lifting restriction of 10 pounds for 8-12 weeks after surgery. This allows time for you to heal from surgery without stressing your surgical sites. If paperwork for your school or employer is needed, discuss it with your surgical team. You may continue to be active with exercises like walking, but no strenuous activities such as lifting more than 10 pounds, bending, pushing/pulling, or having sex until cleared by your surgeon.

 

- Continue to do your breathing exercises every 1-2 hours while awake. This helps exercise your lungs and prevents pneumonia.

 

- Do not submerge in water (bathtub, hot tub, pool, ocean, etc.) while the tube is in place. Unless instructed otherwise, you may shower, but do not let the water hit incisions or tubes directly; just let the water run over those areas. Gently dry with a clean towel. Do not use washcloths or loofahs on incisions.

 

- Check your incisions daily. Your surgical incisions may have surgical glue or sterile strips. Watch for signs of infection (worsening redness, warmth, swelling, or drainage) and call your team if you notice any. Change any dressings according to the directions you were given at discharge.

 

- If you were discharged with a drain in place, empty and record drainage amount and characteristics. You will be given specific instructions at discharge based on the drain, but you will likely need to cleanse the drain site and change the dressing daily. Bring the drainage log with you to your clinic follow-up. Call if there is a significant increase or decrease in the amount of drainage, or if the characteristics change significantly.

 

- Use medications as prescribed at discharge. You will not be able to take medications by mouth initially, so some may have been changed to liquid, or you may need to stop some temporarily. Your team will discuss your home medications with you before discharge. If you were discharged on antibiotics, take them as prescribed until finished. 

 

- When you start taking medications by mouth, you will need to use liquids or crush tablets/open capsules. This will help prevent medications from getting stuck in your esophagus.

 

- Weigh yourself a few times a week and record your weight, especially as you start eating. It is expected for you to lose some weight after an esophagectomy, but it is important to keep an eye on it to make sure you don’t lose too much. Once you start drinking and eating, your tube feeds will be weaned, and your weight will be vital to your progress. Bring your weight log to your clinic appointments.

 

- No driving until cleared by your surgeon. In general, you have to be off any mind-altering medications, as well as be able to move freely and safely perform driving maneuvers before you will be allowed to drive.

 

- If you quit smoking before surgery, do NOT restart.

 

Care of your jejunostomy tube (feeding tube)

Your jejunostomy tube, or j-tube, is what you will use for tube feeds after surgery. Tube feeds will be your main source of hydration and nutrition until you are cleared to eat and drink, and are able to take in enough to sustain you. Your team will give you hands on education before you are discharged from the hospital. Here are some tips for using and caring for your j-tube at home:  

 

• Only pre-made LIQUID medications ordered by your surgical team can be given through your j-tube. Do NOT put crushed medications through your tube. J-tubes are very narrow and clog quite easily with anything other than liquid. 

• Continue your tube feeds as they were ordered at discharge. Depending on how you tolerate tube feeds, you may have tube feeds running over 12 to 24 hours. Follow the instructions for the rate and time that you are given at discharge.

• Water flushes through your j-tube are needed to keep you hydrated and keep j-tube patent. You need to continue water flushes after discharge. If you have a two-bag feeding system at home, the water flushes may be given through that, as well as manually if any liquid medications are given. If you have a single-bag feeding system at home, water flushes will need to be given manually. Frequent flushes help prevent your j-tube from clogging.

• Clean and redress your j-tube site daily. Clean site with mild soap and water, gently pat dry, apply split gauze dressing around tube, and use tape to secure dressing. You may also get a medical mesh stocking to go around your abdomen to hold the tube in place. It is the nature of j-tubes that they may leak some, so it is important to keep the dressing clean and dry so you do not get skin breakdown. If it is leaking some at the site, let your team know so they can make sure there is no infection, help prevent skin breakdown, and suggest a barrier cream.

• If your j-tube becomes sluggish or clogged, to try to help dissolve the clog, you may:

  • Try flushing it with warm water using gentle force;

  • Try using Coca-Cola to flush and let sit in the tube for 1 hour before flushing through with warm water;

  • Try squeezing or milking the tube to help break up a clog;

  • Discuss with your home health team if they are able to assist with unclogging it.

If these methods do not work in unclogging your tube, call your surgeon’s office to discuss next steps. 

For making eating more comfortable and enjoyable

To reduce discomfort:

• Eat small, frequent meals (6 to 8 times per day).  This helps you get the nutrients you need without overfilling your stomach. 

• Take small bites, and chew your food well.  This helps you to swallow and digest your food easier.

• If you choose to eat sweets, eat them at the end of your meal.  Sweets are digested more quickly than other foods.  Eating sweets first could lead to low blood sugar. Also, some sweet foods can make dumping syndrome worse.

• Choose foods that are soft and moist. They may be easier to digest. Avoid gummy foods, such as bananas and soft bread.

• Sit up straight when you eat. This way, gravity can help food move through your digestive tract.

• Keep sitting upright for 30 to 60 minutes after you eat.

• Eat your last meal or snack at least 2 to 3 hours before you go to bed.

To avoid gas:

• Don’t use a straw, smoke, or chew gum. These activities make you swallow air, which can increase gas.

• Avoid foods that produce gas. This includes broccoli, cabbage, cauliflower, corn, dried beans, lentils, onions, and peas.

• Avoid spicy foods.

• Avoid drinks that produce gas. This includes sodas (carbonated drinks), Citrus and tomato products, and drinks with caffeine and alcohol.

Drinking fluids

• Drink most of your fluids between meals. Limit your fluid with meals to ½ cup (4 ounces).

• When you eat snacks, limit fluids you drink with them to 1 cup (8 ounces).

Care of your feeding tube

• Continue tube feeds as ordered at the time of your discharge.

• Flush your J-tube as ordered by your surgeon. Frequent flushes help to prevent clogs in the J-tube.

  • If your J-tube becomes clogged, you can try flushing it with gentle force. If this does not work, you can also try milking the tube and using warm water or Coca-Cola and let it sit in the tube. Sometimes, this can help to dissolve whatever is clogging the tube. If you are still unable to unclog the tube, please call your surgeon's office to discuss the next steps.

• Wash the area around your J-tube daily with soap and warm water.

• Do not submerge in water while your J-tube is still in place. 

• Do not put crushed medications through your J-tube.  This can clog your J-tube.

• You may have some redness or thick yellow drainage near the area where the tube is inserted through the skin. This is normal and does not mean that you have an infection.

• To ease discomfort you can use gauze around the insertion site and use tape to secure the tube to your skin.

Follow-up

You will have a follow-up appointment with your surgical team scheduled prior to your discharge. If an appointment is not given to you, please call clinic to schedule one. Please schedule a follow up with your PCP to update them on your status. Be sure to keep all follow up appointments. 

When to call your surgical team

Call your surgical team if you have any questions related to your surgery or recovery, or if you have any of the following symptoms after your procedure:

• Fever 101.5°F or higher

• Signs of infection at your surgical, drain, or feeding tube sites

• Worsening pain

• Worsening shortness of breath

• Persistent nausea, vomiting, or if not tolerating oral intake

• Consistent diarrhea or constipation

• Feeding tube dysfunction

When to call your primary care provider

Call your primary care provider for the following:

• Burning with urination

• A flare up of a chronic condition, such as gout, migraines, etc.

• Long-term medication questions, such as medications for blood pressure or diabetes

 

Call 911 or go to the emergency room if you are having chest pain, severe shortness of breath, or have any other sudden and severe problems. You can have the emergency team call your surgical team once you are stable.

 

Dietary Progression

 Clear Liquid Diet

When beginning to eat, you will follow a clear liquid diet, which includes:

• Clear juice (such as apple, grape, and cranberry)

• Clear broth (chicken, beef, and vegetable broth without vegetables or meat)

• Flavored gelatin (such as Jell-O®)

• Tea and coffee

• Sports drinks (Gatorade®, Powerade®)

• Clear nutrition drinks (such as Ensure Clear)

• Popsicles

 

Avoid any carbonated drinks (soda, seltzer / sparkling water, tonic water, carbonated alcoholic beverages) after your surgery as these can cause bloating and put stress on the surgical site. Discuss with your surgeon at your postoperative visit when you may try to add these back in. 

 

Full Liquid Diet

When your surgeon determines that you are ready, you will advance to a full liquid diet. Full liquids contains all of the liquids on the clear liquid diet, as well as:

• Blended yogurt (not with pieces of fruits or seeds)

• Cream of wheat or cream of rice cereal

• Ice cream

• Instant breakfast drinks and liquid nutritional supplements (such as Boost® or Ensure®)

• Milk

• Pudding

• Sherbet

• Strained cream soups (not tomato or broccoli)

 

Note: Dairy products (such as milk, cottage cheese, ice cream, pudding) may cause diarrhea right after surgery for some people. You may need to avoid dairy products at first. Try them in small amounts as you advance your diet. You can also try products that are reduced lactose or lactose free.

Soft Diet

A soft diet includes bland, lower-fat, soft foods and drinks. A general rule for a soft diet is any food that you could chew if you did not have teeth. This chart includes foods you can eat and foods to avoid. Remember to follow the eating guidelines above when advancing your diet. 

 

 

Food Group	Foods to Choose	Foods to Avoid
Beverages	Regular milk Tea or coffee Powdered drink mixes Non-citrus juices such as cranberry, grape, apple, or blends of these Nectars	Sodas and other carbonated beverages Alcoholic drinks Citrus juices such as orange, grapefruit, lemon, and lime Drinks that contain herbal ingredients, such as St. John's wart or ginseng
Breads	Pancakes, waffles, and French toast Crackers Toasted bread	Bread, bread products, and crackers that contain nuts, seeds, fresh or dried fruit, or coconut Breads or crackers that are highly sensed (e.g. garlic or onion flavored crackers)
Cereals	Soft cereals (except those listed to avoid)	Coarse cereals such as brain, Grape Nuts, granola Cereals with fresh/dried fruit, coconut, seeds, nuts
Eggs	Hard or soft-boiled, poached, or scrambled	Fried eggs Highly seasoned eggs, such as deviled eggs
Dairy	Cottage cheese, ricotta cheese, cream cheese Mild cheeses (e.g. American, baby Swiss, or mozzarella) Plain or flavored yogurt	Strongly flavored cheese (e.g. sharp cheddar, pepper jack, cheeses that contain other strong seasoning) Yogurt that contains nuts, seeded fruits, or coconut
Fats (eat in moderation)	Butter and margarine Mayonnaise Olive, avocado, or vegetable oils Mildly seasoned salad dressings made with allowed ingredients	Highly seasoned salad dressings, cream sauces, and gravies Bacon, bacon fat, ham fat, lard, and salt pork Fried foods Nuts
Fruits	Canned or cooked fruits or fruit juice (except those listed as foods to avoid) Soft fresh fruits (seedless, without skins, peeled)	Raw vegetables Tomatoes, tomato / vegetable juice (e.g. V-8), tomato juice Gas-producing vegetables like broccoli, Brussel sprouts, cabbage, cauliflower, corn, onions, radishes, rutabagas, sauerkraut, turnips Dried beans, peas, and lentils
Vegetables	Cooked vegetables without seeds or skins (e.g. asparagus tips, baby peas, beets, carrots, chopped spinach, green and wax beans, and winter squash)	Fruits with seeds or skin (e.g. berries, figs, and raisins) Citrus fruits and juices
Meats, fish, poultry, and cheese	Finely ground lean beef, lamb, pork, veal, fish, and poultry prepared any way except fried Casseroles and stews prepared with allowed ingredients	tough meats with gristle fried, highly seasoned, smoked and fatty meats, fish, or poultry such as frankfurters, lunch meats, sausage, bacon, spareribs, beef brisket, sardines, anchovies, duck, and goose chili and other spicy foods shellfish strongly flavored cheeses such as sharp cheese and cheese that contains peppers or other seasonings crunchy peanut butter any yogurt that contains nuts, seeds, coconut, strawberries, or raspberries
Potatoes and starches	Peeled white or sweet potatoes Rice and barley Pasta, such as enriched noodles, spaghetti, and macaroni	Fried potatoes, potato skins, and potato chips Fried, brown, or wild rice Popcorn
Soups	Mildly flavored meat stocks Cream soups made with allowed ingredients	Highly seasoned soups and tomato-based soups
Toppings and Spreads	Sugar, syrup, honey, jelly, and seedless jam Smooth peanut butter	Jam, marmalade, and preserves Chunky peanut butter
Desserts and sweets (in moderation after a meal)	Plain cakes, cookies, and pies Pudding and custard Ice cream, frozen yogurt and sherbet Gelatin, unfilled hard candies made from allowed foods	Desserts that contain chocolate, coconut, nuts, seeds, fresh or dried fruit, peppermint, or spearmint Marshmallows Any candy that contains nuts, seeds, fresh or dried fruit, coconut, peppermint, or spearmint