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Surgery of Your Esophagus

This information explains your surgery of the esophagus and what to expect afterward.

Introduction

You and your doctor have decided that surgery is the best treatment for you. This booklet explains:

  • the operation
  • the care you will receive while you are in the hospital
  • the changes you will have to make in your life as a result of your surgery

The glossary has definitions of italicized words. Your doctor and nurse will discuss all of this information with you in more detail. Please write down any questions and concerns you have so you do not forget them. You can call the doctor or nurse if you won't see them before your operation.

The tumor is in your esophagus (e-sah-fo-gus), or food pipe. You will have an esophagectomy. It is sometimes called an esophagogastrectomy. During surgery, the doctor will remove:

  • the tumor by removing the esophagus in the area of the tumor
  • part of your esophagus above and below the tumor
  • the upper part of your normal stomach below the tumor

This is to make sure that the tumor is completely taken out and that there are no cancer cells in the parts that remain. The remaining part of your stomach is then attached to what is left of your esophagus. Your doctor will:

  • Tell you what the incision will look like
  • Explain how much of your esophagus and stomach is likely to be removed

Preparation

Begin doing at least 30 to 60 minutes of some kind of aerobic exercise each day. It can be walking on a treadmill, using a bicycle, or walking or swimming. This will improve the chance that your recovery will be smooth. If you smoke, stop. This is very important. Discuss it with your doctor. If you like, we can refer you to our smoking cessation program or another one.

You will have pre-surgical testing (PST) within thirty days of your surgery. A nurse will teach you how to do coughing and deep breathing exercises. You will also learn how to use an incentive spirometer (in-sen-tiv-spir-om-eh-ter). These will help to keep your lungs clear of mucous after surgery. They can help prevent an infection in your lungs.

If you are constipated before surgery, you may need a laxative or an enema. Check with your doctor's nurse before surgery. You may require a bowel preparation before surgery, depending on the exact procedure being done. If so, your nurse will review the instructions with you. You will also be given a fact card that describes what you must do.

You will meet with the nurse practitioner (NP) during the pre-surgical testing (PST) visit. The NP will review all of your information. Please bring a list of any medicines that you are taking now. Please tell the NP if you are allergic to any drugs. Also tell the NP if you have any other allergies, e.g., latex allergy. The NP will discuss ways of managing your pain after surgery and will let you know if you need another appointment to see the anesthesiologist. If you are a diabetic, ask the NP how it will be managed.

A staff member from the Admitting Office will call you to tell you when to arrive and where to go. This call will take place on the business day before your surgery. If your surgery will be on Monday, you will be called on Friday. You must not eat or drink anything after midnight the night before your surgery. Take only the medicines that you have been told to keep taking. Take them in the morning with a small sip of water. Your nurse will review these instructions with you. If you develop any fever, cold, cough or skin rashes, please let your MD's office / nurse know.

The nurse is going to explain when and where to report. An NP will see you before you go to the operating room. This is for a final check-up. You may also be seen by the Pain Management team. They may put in an epidural catheter. This small catheter goes in your back. It is the most effective way to control postoperative pain because the medicine goes straight to the pain centers. It also lets you push a button when you have pain. This gives you more control over your pain management.

The Surgical Procedure

During the operation your surgeon will remove your tumor through incisions on your neck and your abdomen or chest. The surgery will take 4 to 6 hours. You will be in the hospital for 10 to 14 days.

After the operation, you may have one or two chest tubes. These exit your chest cavity. They are attached to a drainage unit called a Pleuravac® (plur-ah-vack). They drain air and fluid that normally collects in the chest cavity after the operation. This helps to keep your lung expanded. It is normal for this drainage to be blood-tinged. The chest tube(s) will remain in place for about one week. They will be removed when there is no leakage of air and your fluid drainage is below a certain level.

You will have a small tube called a nasogastric (nay-zo-gas-trick) tube, or NG tube. It goes through your nose into your stomach. It removes gas and stomach fluids, which may interfere with the healing of your incision. The tube also prevents bloating and helps prevent nausea and vomiting.

We must check the amount of urine you produce after your operation. A Foley® catheter will be inserted through your urinary opening (urethra) into your bladder. It will be attached to a drainage bag. You will have it for at least 24 to 48 hours so that your nurse can measure your urine output. If you have an epidural catheter, the Foley® will not be taken out until your epidural catheter is removed.

Your bowels will not function for several days after your operation. You will not eat or drink anything until your bowel function resumes. During that time, you will receive fluids and nutrition through a vein.

After Your Surgery

When you wake up after the surgery, you will be in the Post-Anesthesia Care Unit (PACU). You will remain there overnight. You may still have the breathing tube. It was inserted during surgery to help you breathe. It will probably be attached to a machine. The machine will breathe for you for the first few hours after the surgery. The tube will be removed when you have recovered from anesthesia and have begun to breathe normally without the machine.

The nurses will turn and position you and gently clap your back. That helps free any secretions from your lungs so they remain clear and expanded. When your breathing tube is removed, the nurses will encourage you to do the coughing and deep breathing exercises and use the incentive spirometer. Before you do the exercises, you will receive pain medicine. It will ease the discomfort you will feel when using your chest and stomach muscles. Your nurse will also teach you how to “splint” or support your incisions with a pillow. This will make you more comfortable when you do the exercises. When you return to your hospital room, you should do these exercises every two hours while you are awake.

You will have a patient controlled analgesia (PCA) pump. The PCA pump delivers pain medicine through a vein or in your spinal fluid. It gives you both the dose your doctor prescribes and also lets you push a button if you need more medicine. More information about this is available in the booklet Patient Controlled Analgesia.

You will probably be taken to your room in the morning of the day after the surgery. That afternoon you will get out of bed and sit in a chair. You will also begin walking down and around the hall. It is important to walk after your surgery as soon as your doctor allows it. Walking helps prevent problems with your lungs and circulation.

A valve between the esophagus and stomach normally prevents gastric reflux. This is when gastric juices, bile, and food back up into your esophagus and throat. Some patients with esophageal cancer had reflux disease (GERD) before surgery. In this case, this valve did not work before the operation. Whether or not it worked before surgery, it is removed during surgery. The only way you can prevent reflux after surgery is by not lying flat on your back. Keep your back elevated to about 30 degrees by raising the head of the bed. At home, you can use a wedge under the head of your bed to achieve this angle. Ask your nurse how to do this. Simply putting pillows under your head is not good enough. They just raise your head and not your back.

Your chest tubes will be removed about one week after your operation. You will then have a test called a Barium Swallow. You will drink a barium solution and then have an x-ray. This test will help your doctor see if the stitches in the esophagus and stomach have healed enough for you to begin eating. If the new connection in your esophagus and stomach has healed well, the NG tube will be removed. You will begin taking sips of water, then clear liquids, and finally soft to solid foods.

Dietary Guidelines

Your doctor will review your eating routines with you. After the operation, your stomach will be smaller and it will hold less than it did before the surgery. To get enough food, you will need to eat more often (4 to 6 times a day). The portions will be smaller. You must also chew and eat your food slowly. This prevents your stomach from overfilling, which can cause vomiting. You should have no more than 4 ounces (1/2 cup) of liquid with your meals. This helps to avoid overfilling your stomach. Drink more liquids between your meals to prevent dehydration and constipation. A dietitian will speak to you before your discharge. He or she will review the types of foods you can eat, how often you should eat, and the portions of your meals.

After eating, some patients have diarrhea. They can also have other symptoms such as feeling sweaty, dizzy, and weak. This is called dumping syndrome. Dumping syndrome may occur 15 minutes to 2 hours after you eat. If you have any of these symptoms, call your doctor. Many patients say that avoiding foods with lactose, especially milk, for 2 to 3 months helps. It may also be helpful to decrease the amount of fat in your diet and avoid concentrated sweets. Should problems persist, contact your doctor or dietitian. Until you learn what size portions are right for you, take very small helpings of food. Slowly increase the size. Learning to manage your diet may be difficult at first. With time, patience, and support from your family, you will become familiar with the size of the food portions you can tolerate. If you have any difficulty swallowing or a feeling that food sticks in your esophagus, call your doctor.

Returning Home

Unless you have complications, you will go home 10 to 14 days after your surgery. How quickly you recover depends on your level of physical activity and exercise. In general, the more active you were before your surgery, the faster you will recover. Your doctor will tell you what you should not do when you return home. Ask when you may:

  • go back to work
  • drive
  • lift heavy items (over 5 pounds)
  • vacuum
  • mow the lawn
  • exercise

Increase your activities slowly and steadily.

Wound Area

Inspect your incisions every day. Call your doctor or nurse if you:

  • see any redness
  • have any swelling
  • have any drainage
  • have increased pain in the area
  • develop a fever

Pain

You may have discomfort or pain for up to several weeks after the operation. Your doctor will prescribe medicine to help relieve your pain. Pain medicines often have side effects such as nausea and constipation. Use them only as needed. If your medicine does not relieve your pain or if your discomfort increases, call your doctor.

Breathing Exercises

Continue your coughing and deep breathing exercises at home. These will make certain that your lungs remain clear and free of secretions. Do the exercises at least every four hours when you are awake.

Points to Remember

  • Never lie flat or lie down right after eating or drinking. Always sleep with your head and torso elevated at least 30 degrees with a wedge and avoid going to bed for at least an hour, preferably two hours after a filling meal. A pillow under your thighs can help prevent you from sliding down the bed. Pillows alone do not adequately raise your back and torso.
  • Call your doctor if your pain medicine does not relieve your discomfort enough. An adjustment can be made in the type, dose, medicine, or all of these.
  • The prescription for pain medicine is for one time only. There are no refills. If you need more pain medicine, you must call your doctor's office for a new prescription. It cannot be called into the pharmacy. They must have a written prescription. Call your doctor's office ahead of time so the prescription can be mailed to you before you run out. You do not want to run out of medicine and have nothing.
  • Inspect your incision line daily for any signs of redness, swelling, or drainage. If you see any of these, or if you have increased pain, call your doctor.
  • Do your coughing and deep breathing exercises. They help prevent complications in your lungs.
  • Check with your doctor before you resume:
    • any exercise regimen
    • household chores that include such things as lifting, vacuuming, or mowing the lawn
  • Follow the dietitian's advice on your diet. Eat small meals frequently.
  • Do not smoke or drink alcohol. They irritate your stomach and esophagus.

If you have any questions or concerns regarding your operation, your recovery, please contact your doctor or your nurse. The staff is available and pleased to help you at all times.

Glossary

Barium Swallow: A special procedure to visualize soft tissues on an x-ray.

Dumping syndrome: Signs or symptoms that can occur following the removal of the stomach or portions of the stomach. It is characterized by sweating and dizziness.

Endotracheal tube: A breathing tube inserted into the trachea (windpipe) during surgery to keep the breathing passage open.

Epidural catheter: A very thin tube inserted into the spine to deliver pain medication into the body.

Esophagectomy/Esophagogastrectomy: An operation in which a portion of the food pipe and the upper part of the stomach are removed.

Esophagus: The food pipe or portion of the digestive tract between the pharynx and stomach.

Foley® catheter: A flexible tube inserted into the bladder to drain urine.

Incentive spirometer: A gauge to measure how deeply you are breathing.

Incision: A cut made under sterile technique, as in the operating room.

Nasogastric tube: NG tube, small plastic tube inserted through the nose into the stomach to drain gastric juices out of the stomach.