Download Having oesophageal surgery - Salford Royal NHS Foundation Trust

University Teaching Trust
Information for patients
Having oesophageal surgery
Turnberg Building
Upper GI General Surgery
0161 206 5062
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© G17051005W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017.
Document for issue as handout. Unique Identifier: SURG 20 (17). Review date: May 2019.
Having oesophageal surgery
University Teaching Trust
This booklet has five aims:
Why do I need an operation?
l To help you and your family become better
informed and more involved in your care
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.
l To explain the operation you will be having
l To explain about early recovery after surgery
(ERAS)
l To describe what will happen after the
operation
l 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.
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.
Oesophagus
Cancer
Cancer and
nearby tissue
removed
Stomach
Sometimes patients are offered a course of
chemotherapy before and after the operation
to help treat the cancer.
How is the operation performed?
What is a oesophagectomy?
Oesophagus
Will I need any other treatment if I
have surgery?
Oesophagus
joined to
stomach
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.
Stomach
Small
intestine
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Having oesophageal surgery
University Teaching Trust
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:
lEpidural for pain relief
lIntravenous Infusion (a drip) to give you fluid
and prevent dehydration
lJejunostomy 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.
Jejunostomy feeding can be safely carried out
for many days; we may even send you home
with feeding for a short period. The tube is
painlessly removed
lChest drains - this drains any fluid that may
collect in the chest after the operation. It also
allows the lung to re-inflate
lUrinary 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
lNaso-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
lOxygen - you will be given oxygen via a mask
to help you breath
lWound 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.
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© G17051005W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017.
Document for issue as handout. Unique Identifier: SURG 20 (17). Review date: May 2019.
Having oesophageal surgery
University Teaching Trust
Mobilisation / Physiotherapy
Huffing
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 twice a day, with help from
the nursing staff and the physiotherapists.
Coughing can be uncomfortable and tiring. It
has been found that ‘huffing’ helps to move
phlegm in preparation for coughing.
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.
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.
l 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
l Relax your shoulders
l Take a slow deep breath in through your
nose, concentrating on expanding the lower
part of your chest
l Take a small breath in,
l Open your mouth wide and squeeze the
air forcefully out of your lungs as quickly as
possible (as if steaming up a mirror),
l Your stomach muscles should contract but
your throat muscles should not tighten,
l 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.
l 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
l Place hands or pillow over your stomach
l Take a deep breath in and as you cough
squeeze your hands in over your stomach in
order to support it
l Hold the breath for a count of 3, then slowly
breathe out completely
l Repeat 3 or 4 times
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Document for issue as handout. Unique Identifier: SURG 20 (17). Review date: May 2019.
Having oesophageal surgery
University Teaching Trust
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 push
blood back to your heart. Also remember not
to cross your legs or ankles as this can make the
circulation more sluggish.
l Ankle circling involves moving the feet
clockwise and anti-clockwise in circles.
Repeat 10 times
l Keeping your legs straight bend your feet
firmly up and down at the ankles. Repeat 10
times
l 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 PRACTISE
THESE EXERCISES BEFORE YOU COME
INTO HOSPITAL
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.
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
if 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:
l 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
continued next page
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.
Page 5 of 10
© G17051005W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017.
Document for issue as handout. Unique Identifier: SURG 20 (17). Review date: May 2019.
Having oesophageal surgery
University Teaching Trust
l Cardiac problems. Some patients may
already have heart problems, which may
be exacerbated, by surgery. Having major
operation can put stress on the heart
l 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
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
l Wound infection. Sometimes the wound
gets locally infected and may need treating
with antibiotic
l 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
l 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; 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.
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Having oesophageal surgery
University Teaching Trust
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?
l You may find you need to eat smaller
amounts more frequently ie: little and often
l The dietician may recommend that you have
some nutritious drinks after surgery
l Chew food well and relax after meals
l Sit upright when eating
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?
l Eat small portions of food frequently
l Try to have high calorie foods
l Stick to foods you like
l Try to have nutritious drinks such as milk
shakes, milky coffee
l Use supplement drinks prescribed by
dietician. There are a variety of these
supplements available and you should choose
the one which suites you best
l Initially it is advisable to eat slowly and have
small portions until you know your own
capacity
l If lack of appetite persists and you are losing
weight contact the specialist nurse or your GP
l If you do eat too much at one sitting you
may feel uncomfortable, this is will ease with
resting usually within 30 minutes
How can I gain weight?
l 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
l It will be quite normal for you to loose a little
weight when you first go home
l 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
l The hospital dietician will give you advice
before you go home
l Try to have snacks in-between meals such
as biscuits, chocolate, crisps, milky drinks,
yoghurts
l Eat butter not low calorie spread
l Try to have at least one pint of full cream
milk daily
continued next page
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© G17051005W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017.
Document for issue as handout. Unique Identifier: SURG 20 (17). Review date: May 2019.
Having oesophageal surgery
University Teaching Trust
l 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
l 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 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 to take home with you. 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 chords.
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 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.
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Having oesophageal surgery
University Teaching Trust
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:
l Medical staff
l Specialist Nurses
l Ward nursing staff
l Dietitians
l 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 has a patient support group
that is run every 2 months, ask your specialist
nurse for further information about this.
There is also the Oesophageal Patients Association.
They may be contacted at:
Oesophageal Patients Association
16 Whitfield Cresent
Solihull, West Midlands
B91 3NU
0121 704 9860
For further advice or information please contact:
Upper GI Specialist Nurse
0161 206 5062
07623 604196 pager
07623 606807 pager
07623 622347 pager
[email protected]
Upper GI Surgical Secretaries
0161 206 5472
0161 206 5448
0161 206 5128
Salford Royal Switchboard
0161 789 7373
ask for bleeps 5077 or 2366
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© G17051005W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017.
Document for issue as handout. Unique Identifier: SURG 20 (17). Review date: May 2019.
Having oesophageal surgery
University Teaching Trust
For further information on this leaflet, it’s references and sources
used, please contact 0161 206 5062
If you need this interpreting please telephone
Copies of this information are
available in other languages
and formats upon request.
In accordance with the
Equality Act we will make
‘reasonable adjustments’
to enable individuals with
disabilities, to access this
treatment / service.
Email: [email protected]
Under the Human Tissue Act 2004, consent will not be required
from living patients from whom tissue has been taken for
diagnosis or testing to use any left over tissue for the following
purposes: clinical audit, education or training relating to human
health, performance assessment, public health monitoring and
quality assurance.
If you object to your tissue being used for any of the above
purposes, please inform a member of staff immediately.
Salford Royal
operates a
smoke-free policy.
For advice on stopping
smoking contact
the Hospital Specialist
Stop Smoking Service
on 0161 206 1779
Salford Royal NHS Foundation Trust
Stott Lane, Salford,
Manchester,
M6 8HD
If you would
like to become a
Foundation Trust
Member please visit:
If you have any suggestions
as to how this document
could be improved in the
future then please visit:
Telephone 0161 789 7373
www.srft.nhs.uk/
for-members
http://www.srft.nhs.uk/
for-patients
www.srft.nhs.uk
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© G17051005W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017.
Document for issue as handout. Unique Identifier: SURG 20 (17). Review date: May 2019.