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  • How to Care for Patients after an Esophagectomy A Nursing Guide
  • About MeEducationCertifications Medical ExperienceResearch Involvements
  • 1. Review the normal anatomy of the upper gastrointestinal tract 2. Highlight the steps of an esophagectomy 3. Explain the physiologic changes after surgery 4. Clarify the 30 degree rule 5. Discuss why daily amylase levels are drawn 6. Reinforce the importance of postoperative ambulation 7. Outline the postoperative dietary restrictions
  • This presentation will teach new nurses how to care for patients who have had an esophagectomy. The overall goal is to decrease the most common postoperative complications in this patient population.
  • Lets start by reviewing the normal anatomy of the esophagus and stomach.
  • Before getting started, I would like to briefly introduce myself. 
  • Please dock the robot.
  • The agenda for today's talk is to review the preoperative anatomy of the esophagus and stomach, to highlight the steps of an esophagectomy, to explain the physiologic changes postoperatively, to clarify the 30 degree rule, to discuss the need for daily amylase levels, to reinforce the benefits of early mobility, and to outline dietary changes.
  • How does the anatomy change after surgery?
  • Good question...
  • The esophagus is a four-layered tube that is about 35 centimeters long.1 It starts at the sixth cervical vertebrae and ends just below the diaphragm.1 The lower esophageal sphincter allows food to pass into the stomach and helps prevent acid reflux. Acid reflux is a common cause of Barrett's esophagus and subsequently esophageal cancer.
  • Head of bed at 30 degrees please!
  • Once esophageal cancer is found, surgery is offered as a curative option for early-staged disease. The major steps of an esophagectomy are dissection and mobilization of the stomach, creation of the gastric conduit, dissection of the esophagus, removal of the esophagus, and substitution of the gastric conduit as the new esophagus.2
  • It's time to check the drain amylase level.
  • The stomach is reconstructed into a tubular structure with the gastroepiploic artery preserved.2 When the diseased portion of the esophagus and the proximal stomach is removed, the lower esophageal sphincter is removed as well. This is significant because the stomach does not have peristalsis like the esophagus does, so food must empty from the gastric conduit by gravity.
  • Do I have to get up and walk?
  • Yes, this is the first of three walks today.
  • After an esophagectomy, patients must have their heads above 30 degrees at all times when awake or sleeping to prevent aspiration. The lower esophageal sphincter is removed during an esophagectomy, so the patients are at increased risk for acid reflux.
  • Amylase is an enzyme that is produced in the saliva and begins the breakdown of carbohydrates in the mouth. If a patient has an anastomotic leak after surgery, the amylase level will be high in the Jackson-Pratt drain. This drain is placed intraoperatively behind the anastomosis site.
  • Okay.
  • Ambulation is important to prevent blood clots, constipation, and pneumonia. Walking also improves muscle tone and psychological well-being.
  • You are limiting what I can eat?
  • Liquids and soft foods only.
  • Summary
  • Credits & References1. Overview of esophageal and proximal stomach malignancy. http://accesssurgery.mhmedical.com/content.aspxbookid=1317&sectionid=724269442. Ivor lewis esophagectomy. http://accesssurgery.mhmedical.com/content.aspx?bookid+1317&sectionid=72427480.
  • After an esophagectomy, the stomach size is significantly reduced, so the patients are encouraged to eat small "meals" every 2 hours or 6-8 times a day. This is a change from eating 3 large meals prior to surgery. The diet is advanced slowly from clear liquids, to full liquids, and then to a soft diet. If everything goes well, the patient will eventually have a regular diet months down the road.
  • Image Attributions: (https://pixabay.com/photos/knowledge-book-library-glasses-1052010/) - DariuszSankowski - License: Free for Commercial Use / No Attribution Required (https://creativecommons.org/publicdomain/zero/1.0) (https://pixabay.com/photos/book-agenda-table-notes-notebook-3043275/) - DarkWorkX - License: Free for Most Commercial Use / No Attribution Required / See https://pixabay.com/service/license/ for what is not allowed (https://pixabay.com/photos/clinic-medical-health-care-disease-1807543/) - sasint - License: Free for Commercial Use / No Attribution Required (https://creativecommons.org/publicdomain/zero/1.0) (https://pixabay.com/photos/light-bulb-lightbulb-light-bulb-1246043/) - Free-Photos - License: Free for Commercial Use / No Attribution Required (https://creativecommons.org/publicdomain/zero/1.0) (https://pixabay.com/photos/puzzle-last-particles-piece-654957/) - 422737 - License: Free for Commercial Use / No Attribution Required (https://creativecommons.org/publicdomain/zero/1.0)
  • In summary, optimal nursing care is essential to prevent postoperative complications and provide education in this complex patient population. Thank you for your time and attention.
  • A special thanks to the doctors and nurses for their ideas in the development of this quality improvement project.

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