2016 esophageal surgery - nova scotia health …...1 introduction you are being admitted to the...

Please bring this book to the hospital on the day of your surgery.

Esophageal Surgery

www.nshealth.ca

Patient & Family Guide2016

DisclaimerThis is general information developed by The Ottawa Hospital and adapted by the Nova Scotia Health Authority. It is not intended to replace the advice of a qualified healthcare provider. Please consult your healthcare provider. They will be able to determine the appropriateness of this information for your specific situation.

Used with the permission of The Ottawa Hospital. All rights reserved. No part of the contents of this book may be produced or transmitted in any form or by any means, without the written permission of The Ottawa Hospital, Clinical Pathway Project Team.

© The Ottawa Hospital, June 2002 (Revised 2008)

Contents

Introduction ............................................................................................................... 1Healthcare Team ........................................................................................................ 5Preparing For Surgery ................................................................................................ 7Esophageal Surgery ................................................................................................... 9

Esophageal cancer ............................................................................................ 9Surgery............................................................................................................. 10

After surgery: Acute phase ....................................................................................... 11Information for family members .................................................................... 12

After surgery: Recovery phase ................................................................................. 13Pain management ........................................................................................... 13Intravenous (IV) ............................................................................................... 14Chest tube drainage ....................................................................................... 14Nasogastric tube ............................................................................................ 15Jejunostomy tube (J-Tube) ............................................................................ 15Urinary catheter .............................................................................................. 15Wound care ...................................................................................................... 15Oxygen ............................................................................................................. 16Deep breathing and coughing ........................................................................ 16Ankle exercises ................................................................................................ 17Moving in bed .................................................................................................. 17Getting out of bed ........................................................................................... 17Post-op (post-operation) exercises ................................................................ 18

Preparing to go home .............................................................................................. 21Discharge planning ......................................................................................... 21

At home ..................................................................................................................... 22Activity ............................................................................................................. 22Wound care ...................................................................................................... 22Medication(s) ................................................................................................... 23

Esophageal Soft Diet ................................................................................................ 24When to call for help ....................................................................................... 29

Resources ................................................................................................................. 30

1

IntroductionYou are being admitted to the Victoria General Hospital at the Nova Scotia Health Authority (NSHA) for esophageal surgery. This book will tell you how to prepare for surgery, your hospital stay, and care at home after surgery.

The healthcare team has put together a Clinical Pathway so you will know what will happen to you before surgery and on a day-to-day basis after surgery. A Clinical Pathway is a general guideline about your care. Please refer to pages 2 and 3 of this guide.

Make sure to read this guide and bring it with you to the hospital. The healthcare team will refer to this guide during your hospital stay.

The Thoracic Clinic is located at the Victoria General Hospital, Dickson building, 1st and 4th floors. Dr. D. Bethune Office: 902-473-6692 Dr. H. Henteleff Office: 902-473-5685 Dr. A. Mujoomdar Office: 902-473-8337 Dr. M. Plourde Office: 902-473-2281

2

Clinical Pathway – Esophageal Surgery: Acute PhasePre-admission Day of

Admission/surgery PRE-op

Day of admission/surgery POST-op

Post-op day 1 Post-op day 2

Tests • Blood work• Chest X-ray • ECG• Lung tests• Urinalysis

• Blood work (if ordered)

• Blood work • Chest X-ray• ECG

• Chest X-ray• ECG

• Chest X-ray• ECG

Consults • Physiotherapy • Physiotherapy• Respiratory therapy

• Dietitian

Treatments • Intravenous (IV)

• Epidural catheter• Chest tube• Wound dressing• Urinary catheter• IV• Nasogastric tube• Jejunostomy tube

(J-Tube)• Arterial catheter• Breathing tube

(ventilator)• Jackson-Pratt (JP) drain

• Epidural catheter• Chest tube• Wound dressing• Urinary catheter• IV• Nasogastric tube• J-Tube• Arterial catheter• Breathing tube

(ventilator)• JP drain

• Epidural catheter• Chest tube• Wound dressing• Urinary catheter• IV• Nasogastric tube• J-Tube• Arterial catheter• JP drain

Medications • Antibiotic • Patient-

specific medications

• Patient-specific medications

• Pain medication: epidural/paravertebral nerve block

• Oxygen• Bronchodilators







Activity • Regular activity

• Bedrest • Head of bed up• Dangle legs• Up in chair 1-2 times

per day• Range of motion & leg

exercises, including hip flexion 4 times per hour while awake

• Deep breathing & coughing every hour while awake

• Chest physio

• Head of bed up• Deep breathing &

coughing every hour while awake

• Up in chair 2 or more times per day

• Walk with help once per day as tolerated

• Range of motion & leg exercises, including hip flexion 4 times per hour while awake

Nutrition • Nothing by mouth after midnight the night before surgery

• Nothing by mouth • Nothing by mouth until swallowing test (about 5-7 days)

• Nothing by mouth until swallowing test (about 5-7 days)

Patient & Family Teaching/ Discharge Planning

• Review Clinical Pathway instructions & patient booklet › skin prep; bowel prep

• Discharge plans & length of stay

Patient teaching• Review day

of surgery events

Patient teachingReview: › activity › deep breathing & coughing › pain control goals

3

Clinical Pathway – Esophageal Surgery: Recovery PhaseDay 1 Day 2 Day 3 Day 4

Tests • Chest X-ray

Consults • Physiotherapy

Treatments • Epidural catheter• Wound dressing• Neck dressing• Urinary catheter• IV• Nasogastric tube• J-Tube• Chest tube• JP drain

• Epidural catheter• Wound dressing• Neck dressing• Urinary catheter• IV• Nasogastric tube• J-tube• Chest tube• Weight• JP drain

• Removal of epidural catheter and urinary catheter as applicable

• Remove wound dressing• Neck dressing• IV• Nasogastric tube• J-tube• Chest tube• JP drain

• Removal of epidural catheter and urinary catheter as applicable

• Neck dressing• IV• Nasogastric tube• J-tube• Chest tube• JP drain

Medications • Patient-specific medications

• Pain medication: IV/Paravertebral Nerve Block/Epidural

• Oxygen• Bronchodilators• Anticoagulant• Laxative









• Bronchodilators• Anticoagulant• Laxative

Activity • Head of bed up• Post-op exercises from

patient education booklet

• Up in chair for 1 hour, 2 times per day

• Activity as tolerated• Walk in hall with

assistance 3-5 times per day

• Head of bed up• Up in chair for 1 hour, 3

times per day• Activity as tolerated• Walk in hall with help

more than 5 times per day

• Review / revise exercise plan as needed by physio

• Head of bed up• Up in chair more than 3

hours per day• Activity as tolerated • Walk in hall more than 5

times per day

• Head of bed up• Up in chair more than 3

hours per day• Activity as tolerated• Walk in hall more than 5

times per day

Nutrition • Nothing by mouth until swallowing test (about 5-7 days)

• Nothing by mouth• J-tube feed




• Patient/Family teaching – reinforce: › deep breathing & coughing › foot & ankle exercises › diet › pain control goals › ensure patient has education booklet

• Discharge planning: assess for issues affecting discharge & follow-up as appropriate

• Patient/Family teaching – reinforce: › pain control goals › activity






4

Clinical Pathway – Esophageal Surgery: Recovery PhaseDay 5 Day 6 Day 7 Day 8 Day 9

Tests • Hypaque swallow • Chest X-ray

Consults • Home Care

Treatments • Neck dressing• IV• Removal of

nasogastric tube• J-tube• Chest tube• Weight• JP drain

• Neck dressing• IV• J-tube• Removal of chest

tube• Removal of JP

drain

• Removal of neck dressing

• Stop IV solution• J-tube

Medications • Patient-specific medications

• Bronchodilators as needed

• Anticoagulant



• Anticoagulant





Activity • Head of bed up• Activity as

tolerated• Continue walking

more

• Head of bed up• Activity as

tolerated• Continue walking

more

• Head of bed up• Independent

activity as tolerated





Nutrition • Nothing by mouth• J-tube feed

• Clear fluids• End J-tube feeds

• Full fluids • Esophageal Soft Diet

• Esophageal Soft Diet


• Patient/Family teaching: › ongoing teaching as required › pain control goals


• Patient/Family teaching: › ongoing teaching from patient education booklet › J-tube flush › Esophageal Soft Diet

• Discharge planning: › review discharge plan with patient / family

• Patient/Family teaching:

• ongoing teaching from patient education booklet

• dietitian to do diet teaching

• Review discharge instructions: › J-tube flush › wound care › activity › signs and symptoms to be reported to doctor

• Discharge planning: › review discharge plan with patient / family

• Discharge planning: › prescriptions written › confirm 11 a.m. discharge plans with patient / family › confirm patient / family have any questions answered about the Esophageal Soft Diet › follow-up medical appointments made › make sure patient has all required teaching booklets

• Discharge planning: › prescriptions provided › follow-up medical appointments provided › discharge by 11 a.m.

5

Healthcare TeamThese members of the healthcare team will help you during your hospital stay.

Thoracic SurgeonThe thoracic surgeon and team of surgical residents will talk about your care with you and answer any questions you have. The thoracic surgeon will be in charge of your care.

Nurse PractitionerThe nurse practitioner (NP) works with the surgeons and residents. The NP will help you manage any acute or chronic conditions, prescribe medications, order and interpret laboratory or diagnostic tests, and perform procedures.

Registered Nurse and Licensed Practical NurseRegistered nurses (RN) and licensed practical nurses (LPN) will care for you before and after your surgery. They provide emotional support, medications, nursing care, and teaching instructions.

PhysiotherapistThe physiotherapist (PT) will help you with getting out of bed, walking, deep breathing, coughing, and arm and shoulder exercises.

Social WorkerSocial work services can be accessed at any point during your hospital stay. A social worker will meet with you and your family for counselling, community information, and discharge planning services as needed. Before and after your surgery, you may feel a variety of emotions, such as fear, sadness, anger and/or loss of control. Sometimes help is needed to cope with these feelings.

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DietitianThe dietitian will help you after your surgery by reviewing your nutritional needs and teaching you about your diet after surgery.

Home CareThe Care Coordinator will meet with you a few days before you leave the hospital to make plans for nursing care at home.

Intensive Care Unit (ICU)The ICU team is made up of doctors, nurses, physiotherapists, and respiratory therapists. Although you will remain under the care of your thoracic surgeon, your care will be managed by the ICU team while you are in the intensive care unit.

Intermediate Care Unit (IMCU)The IMCU team includes doctors, nurses, a physiotherapist, a respiratory therapist, a social worker, a dietitian, and an occupational therapist. The 6th floor IMCU is a monitoring unit located on the Thoracic Unit.

6A Thoracic UnitThe team includes doctors, nurses, physiotherapists, respiratory therapists, a social worker, a Continuing Care Coordinator, a dietitian, and an occupational therapist.

Acute Pain Service (APS) TeamThe Acute Pain Service includes anesthetists and nurses who are specially trained to help people with their pain. The pain team will see you once or twice a day for the first few days.

7

Preparing For Surgery

Helpful points before coming to hospital• Stop smoking! Avoid tobacco in any form. This includes pipes, cigars,

cigarettes, and chewing tobacco. Tobacco smoke has many harmful substances that damage cells. Over time these cells can become cancerous. Smoking also places you at risk for lung complications after surgery. Tobacco smoke destroys cilia (lining of the airway). Cilia help clear secretions (mucus). As a result, you will be less able to clear secretions after surgery.

• Even shortly before surgery, stopping smoking helps recovery. It is never too late to stop smoking. Smoking cessation programs that can help you stop smoking include:

� Getting Started Sessions › This service is a 1 hour information session where participants

get information about the stopping process as well as options for follow-up support. The program is completely free. Getting Started Sessions are offered on a regular basis throughout NSHA.

� Keeping it Going Sessions › This is a 4 week program where participants receive a workbook,

tips, advice and strategies, and an invitation to try Nicotine Replacement Therapy (NRT) to support them in their efforts to be tobacco-free.

• If you would like to know more about what Stop Smoking Services can do for you, please call 902-424-8866. Another helpful resource is the Lung Association of NS; please call 902-443-8141.

• Make plans for help in your home after surgery before going to the hospital. • Look at your Clinical Pathway so you and your family know what to expect on a

daily basis.

8

Pre-admission visit• You will have blood tests, urinalysis (urine test), electrocardiogram (heart test),

and a chest X-ray. • An anesthesiologist (doctor who gives you sleeping medication during surgery)

will ask you questions about your health, and explain your anesthetic (sleeping medication) and pain control.

• A nurse will ask you questions and tell you about leg, breathing, and coughing exercises, pain control, and skin preparation. It is helpful if you practice deep breathing and coughing exercises before your surgery (see page 16).

Day before and day of surgery• Do not eat or drink after midnight the night before your surgery. If you have

been told to take your usual medication on the morning of surgery (for example, your blood pressure pills or heart pills), use only a sip of water.

• Do not smoke or drink any alcohol 24 hours before surgery. • Bring in both home and work telephone numbers of your spouse or a relative

who will be helping you, so they can be contacted if needed. • Bring your personal care items, such as a toothbrush, comb, shampoo, and

cream. Do not bring scented products. The QEII is scent-free.• Leave your personal valuables at home. • If you have a personal directive, please bring a copy with you. • Bring in appropriately fitting footwear such as sneakers.

9

Esophageal Surgery

Esophageal cancerThe esophagus is a hollow tube that carries food and liquid from the throat to the stomach. The esophagus is located in an area called the mediastinum. This area also has the heart, trachea (windpipe), and many lymph nodes. The lungs are separated by the mediastinum.

Cancer of the esophagus is a disease in which cancer (malignant) cells are found in the tissues of the esophagus. Cancer may develop at any point along the esophagus. Most often the cancer develops in the mid to lower third of the esophagus. The most common sign of cancer of the esophagus is having a hard time swallowing that is getting worse. Pain may be felt when swallowing, or coming from behind the breastbone.

Windpipe (trachea)

Esophagus

Stomach

Large intestine (colon)

Small intestine

Treatment for cancer of the esophagus and the chance of recovery (prognosis) depend on several factors. These include the type of cancer cells, size, location in the esophagus, extent of the tumour (whether it is just in the esophagus or if it has spread to the lymph nodes or other parts), and the person’s age, general health, and feelings about treatment. Cancer of the esophagus usually cannot be cured unless it is found in the earliest stages, before it has begun to spread. Treatment is available for esophageal cancer that has spread, to help symptoms.

Esophageal cancer can be treated by:• Surgery (taking out the cancer in an operation) • Radiation therapy (using high-dose X-rays to kill cancer cells) • Chemotherapy (using drugs to kill cancer cells)

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Depending on your needs and the extent of the disease, you may have more than one treatment method. You may be referred to doctors who specialize in different kinds of cancer treatment. Often, specialists work together as a team to plan and carry out your care. The team may include a thoracic surgeon, medical oncologist (cancer specialist), radiation oncologist, nurse, dietitian, and social worker.

SurgerySurgery is a common treatment for cancer of the esophagus. The thoracic surgeon may remove all or part of the esophagus and part of the stomach in an operation called an esophagectomy or esophago-gastrectomy. During the procedure, an incision (cut) may be made in the chest, abdomen, and neck.

The chest wall incision will usually go from mid-back around to mid-front. The surgeon takes the tumour out along with part of the esophagus, nearby lymph nodes, and other tissue in the area. Usually, it is possible to connect the stomach to the remaining part of the esophagus. In a few cases, the surgeon forms a new passageway from the throat to the stomach, using tissue from another part of the digestive tract (such as the colon or small bowel) to replace the esophagus. If a tumour blocks the esophagus but cannot be removed, the surgeon may be able to create a new pathway to the stomach (a bypass). In some cases, the surgeon can dilate (widen) the esophagus and place a stent (synthetic tube). This procedure may have to be repeated as the tumour grows. During surgery, a feeding tube (jejunostomy or J-Tube) is often placed in the bowel for extra nutritional needs.

The surgery is done under a general anesthetic, so you will not be awake. The length of surgery depends on the extent of the disease, and may take up to 8 hours. After surgery, you will be taken to the Post-Anesthetic Care Unit (PACU) followed by the Intensive Care Unit (ICU) for 24-48 hours and then to the Intermediate Care Unit (IMCU) on the Thoracic Surgery Unit.

11

After surgery: Acute phaseYour doctor may have told you that you will be in the Post-Anesthetic Care Unit (PACU), followed by the Intensive Care Unit (ICU) after your surgery. This is because you need closer observation, monitoring, and nursing care than can be provided on a regular unit.

The nurses have extra training and they care for only 1 or 2 patients at a time. Although you will remain under the care of your admitting doctor, your medical care will be managed by a team of specialized doctors during your stay.

You will be taken to the Thoracic Unit when you no longer need frequent observation and monitoring in the ICU. This is usually after 1-2 days.

You may need help to breathe for a while. If so: › A tube will be placed through your mouth, down your windpipe, and into

your lungs. This tube will be attached to a breathing machine (ventilator). › You will not be able to speak, eat, or drink until this tube is taken out. The

nurses will ask you simple questions that you can answer with a nod. › You will not be able to cough mucus from your lungs in the usual way. To

remove the mucus, the nurse will place a small suction tube through the breathing tube.

› Your throat may feel sore from this tube. This tube is usually removed within a day. It may be kept longer if you have any trouble with your breathing.

Several monitoring devices will be used. These include:1. A cardiac monitor to observe your heart function.

2. A clip attached to your finger to monitor the oxygen levels in your blood.

3. 1-2 intravenous (IV) lines in your arm, and 1 in your neck.

4. A small tube placed in an artery of your wrist for frequent blood tests and blood pressure measurement.

You will also have other tubes including a chest tube, nasogastric tube, J-Tube, JP drain, and urinary catheter (see pages 14-15).

12

Controlling your pain is important. You will receive medication for the first few days via an epidural catheter or paravertebral nerve block (small catheter inserted into your back delivering small amounts of medication continuously). Do not hesitate to tell your nurse when you are having pain (see pages 13-14).

Information for family membersThe ICU Family Lounge is on the 3rd floor. Each time you wish to visit a patient in the ICU, you must first check in at the front desk on 3A. When you arrive, the clerical staff will check with ICU staff to make sure visitors can go in. The ICU limits visiting from 6:30–8 a.m. and from 6:30–8 p.m., when the nurses are changing shifts. If not already received, you can ask for a detailed ICU visitor’s pamphlet on your first visit to the ICU.

Only 2 visitors at a time can visit you in the 6A Intermediate Care Unit. Visitors are asked to check in at the nursing station on 6A when they arrive. The unit staff will check with the IMCU staff to make sure it’s a good time to visit.

13

After surgery: Recovery phasePain managementPain is personal. The amount or types of pain you feel may not be the same as others feel, even for those who have had the same operation. The goal is well-controlled pain at rest and with activity. With good pain control at rest, you will be comfortable enough to sleep. With activity, there may be some increase in pain but the pain should not stop you from coughing, deep breathing, and moving about as well as you like.

Pain control can help you:• Have greater comfort while you heal. • Get well faster – with less pain you can start to walk, do your breathing

exercises, and get your strength back more quickly. • Avoid problems such as pneumonia and blood clots. • Leave the hospital sooner. With epidural analgesia or a paravertebral nerve block, you will have a pump that has medication(s) to help control your pain. The pump will be connected to a small tube in your back, delivering medications such as painkillers (opioids) and/or freezing (local anesthetic). This method, as well as type of pain medication will be decided by your anesthesiologist (the doctor who will put you to sleep for your surgery) and you.

• Epidural: the anesthesiologist may control your pain by giving you an epidural. This is a small tube inserted in your back. The tube is attached to a pump with a bag of medicine. The pump sends the pain medication to you on an “around the clock” basis. You will still be able to move around and walk with this kind of epidural.

• Paravertebral Nerve Block (PVB): a small tube about the size of a fishing line is placed near the area where the surgery was done. The tube is attached to a pump with a bag of medicine. The pump sends the drug to you on an “around the clock” basis. The medication “freezes” or “numbs” the area where you had surgery.

Your pain will be assessed using a scale of 0–10. Zero is no pain and 10 is the worst pain possible. You will be asked to rate your pain level, both while resting and during activity. In addition, you will be asked if the pain stops you from moving and if you are satisfied with your pain.

14

If you have received ‘freezing’, the nurse will ask you to move your legs and will also test the feeling around your epidural catheter. These assessments will help determine how effective your treatment is and whether changes in the pump or medication are needed.

Tell your nurse if you have any of the following:

› Itchy skin › Nausea and/or vomiting (feeling sick to your stomach and/or throwing up) › Pain that is not getting better › Heaviness in your legs › Tingling or numbness › Increased sleepiness

After a few days, when you can have pain medication another way, the pump will be stopped. You may take pain medication by mouth, through your subcutaneous layer (fatty tissue just below skin surface), or through the J-Tube.

Intravenous (IV)You will have an IV to replace your fluids until you are able to drink well. Do not pull on the IV tubing. When you are walking, push the IV pole using your hand that does not have the IV.

Chest tube drainage After chest surgery, extra air and fluid tend to collect in the chest cavity. One or two chest tube(s) will be placed around your lung. The chest tube is connected to a drainage system to help drain the fluid and air.

Expect to see blood in the tube(s) for the first couple of days; this is normal. The tube(s) should clear after a couple of days. An X-ray of your chest will be taken to decide when the tube(s) should come out. The tube(s) will usually be removed after a week.

Do not lie on the chest tube(s) while in bed. Do not pull on the tube(s). You will be helped to walk in the hall while the chest tube(s) is/are in place. Tell your nurse if you find it hard to breathe.

15

Nasogastric tube You will have a tube placed down your nose and into your stomach. This nasogastric tube (N/G tube) drains fluid from your stomach while you are healing and will be connected to wall suction. The tube is usually removed after a week, when a test called a ‘barium swallow’ shows no leaks.

Jejunostomy tube (J-Tube)You will have a tube inserted through your abdomen into a part of your small bowel (jejunum). This J-Tube will be used to feed you starting the first day after your surgery and until you are able to eat food by mouth. The dietitian will review your nutritional needs and recommend the nutritionally complete formula for you to get through the J-Tube. You will leave the hospital with this tube in place in case you need it for feeds at home. While in hospital, the nurse will flush the tube to keep it open. We will teach you and your family how to take care of and flush this tube for when you are at home.

Urinary catheterYou will have a urinary catheter (tube) to drain urine out of your bladder for a few days. The nurse will clean your catheter site every 8 hours to prevent infection.

Wound careYou will have an incision (cut), which usually goes from mid-back around to mid-front. The incision is usually closed with stitches or staples and protected with a dressing. The bandage is usually removed after a few days.

You will have a small incision and a drain (JP drain) at your neck. This drain will help to remove fluid. A small bandage will cover this drain and will be changed each day. The drain will be removed after a few days when there is little drainage.

You will have a dressing at your chest tube site that will be changed every 3 days or as needed.

16

OxygenOxygen is an important part of the air we breathe. Sometimes the body may need extra oxygen. These reasons may include lung disease, heart disease, and the demands of surgery. Extra oxygen can help get oxygen levels in the blood and body tissues back to normal, and help make things easier on your heart and lungs. During your hospital stay, you may receive extra oxygen. This is given through a mask over your nose and mouth or small tubes in your nostrils (nasal cannula).

The amount of oxygen in your blood is tested with a small clip placed on your finger. This is called pulse oximetry. This test checks that your body is getting the right amount of oxygen. When you no longer need extra oxygen, the clip will be removed.

Deep breathing and coughingThe lungs exchange oxygen and carbon dioxide. Oxygen passes into the bloodstream from tiny air sacs called alveoli and is carried to the cells. The cells need oxygen to live and carry out their normal functions. The lungs also get rid of carbon dioxide, a waste product of the body’s cells. Usually, the alveoli stay open because we tend to take large breaths. Because of surgical procedures, anesthesia, pain, or immobility (not moving your body), we tend to take smaller breaths which may cause the alveoli to close. Deep breathing and coughing exercises after surgery will help keep your lungs healthy.

Deep breathing exercises work best when you are sitting up in a chair or on the side of the bed.

Support your incision with a small blanket or pillow.1. Take a deep breath in through your nose. Hold for 2-3 seconds. Breathe out

through your mouth slowly.2. You may also use the incentive spirometer by putting your lips tightly around

the mouthpiece. Breathe in deeply and try to hold the ball up as long as you can. Remove the mouthpiece, breathe, and rest for a few seconds.

Repeat either of these 2 exercises 10 times every hour while you are awake and until your activity level increases.Coughing exercises help to loosen any secretions that may be in your lungs. These can be done after your first 5 deep breaths.

17

To produce an effective cough: › Support your incision with your pillow or blanket. › Take a deep breath and cough.

Ankle exercisesThese exercises help the blood circulate in your legs while you are less active. Do these 10 times every hour while you are awake, until your activity level increases.

With your legs flat on the bed:

1. Point your feet toward your body.

2. Point your feet away from your body.

3. Move your ankles in a circle clockwise, and then counter-clockwise.

Moving in bedWhile you are in bed, it is important to move. Do not worry about the tubes you have in place, just avoid lying on your incision and chest tube. Move at least every 2 hours while you are awake.

• Support your incision with a small blanket or pillow. • Bend your knees and roll (for example from your non-operative side to your

back).

Getting out of bed• Do not get out of bed by yourself for the first time. A nurse will help you.• Bend your knees and roll onto your side where there is no incision. Place your

upper hand on the bed below your elbow. • Raise your upper body off the bed by pushing down on the bed with your upper

hand and pushing up with your lower elbow. • Swing your feet and legs over the edge of the bed and bring your body to a

sitting position. • If you feel lightheaded, rest for a few minutes and call your nurse to help you.

18

Post-op (post-operation) exercisesThe physiotherapist will supervise and help you in the progression of this exercise program. Each exercise should be repeated 10 times every hour at first, unless you’re told otherwise. Continue to do this program when you are at home. Some exercises will help keep your airway clear and free of mucus and help to avoid breathing problems such as pneumonia. Others will generally get you active in the recovery period.

Deep breathing exercises

• Sit with your hands on either side of your rib cage.

• Breathe in deeply.• Blow air out of your mouth slowly.

Your rib cage should expand sideways against your hands.

• Sit with your hand placed gently on your stomach just below your rib cage.

• Breathe in deeply and blow air out. You should feel your stomach expand as you breathe in. This is diaphragmatic deep breathing.

19

Arm and shoulder exercises

• Sit with your fingertips on your shoulders.

• Circle your elbows.

• Lift your arms in front of you above your head, with elbows straight, while breathing in.

• Lower your arms slowly while breathing out.

• Sit and lift your arms sideways, with your elbows straight and palms facing the ceiling.

• Reach for the ceiling.

• Sit or stand with your arms loose or crossed in front of you.

• Slowly lift your arms up, out to the side and back.

• Sit with your arms crossed in front of you, and your hands on shoulders.

• Turn your body to the right and left.

• Sit.• Bend forward,

moving your head toward your knees, then return to a sitting position.

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NOTES• If you are concerned about using stairs at home, these can be practiced with

help before you leave the hospital. • Continue with the exercises 2-3 times every day for at least 2 weeks while your

incisions are healing. • Check your posture often in front of a mirror. You may tend to lean towards

your operated side and that shoulder may drop down and forward. Watch for this and correct it.

• Progress all your activities slowly over time. Let pain be your guide! Talk about increasing your activity level with your surgeon at the follow-up appointment.

• Remember, exercises are needed in the recovery phase but rest is also important!

If you have any questions, please ask.

We are here to help you.

Notes:

21

Preparing to go home

Discharge planningWhen you are discharged from the hospital, you may need general help at home. It is best to make plans before going to the hospital. Talk about your discharge plans with your nurse.

You may have concerns about how you will manage once you return home.

These might include such issues as:

› I live alone. How will I manage? Who will make my meals? › I’m worried and scared. Who can I talk to? › I have young children and I’m told I can’t lift anything. What do I do? › My partner is sick. Who will take care of him or her while I’m in the hospital?

If you have any concerns, ask to see a social worker as part of your discharge plan.

Plan for someone to pick you up at 11 a.m. on the day of discharge. You will receive a prescription for medication. You will be given a follow-up appointment to see your thoracic surgeon in about 3-5 weeks. You will be told of your follow-up appointment date and time by mail or phone.

Be sure you understand the information you’ve been given about:

› Esophageal Soft Diet › Activity › Follow-up visit(s) › J-Tube care › Medications › Post-thoracotomy exercises › When to call the doctor › Wound care

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At home

Activity• Continue with the shoulder and arm exercises, deep breathing exercises, and

walking as talked about with your physiotherapist. • Stairs are encouraged and are a great exercise during your recovery. • Avoid hard exercise, including lifting heavy objects such as grocery bags, snow

shovelling, and pushing a lawn mower, until after you have seen your doctor for your follow-up appointment.

• Do not lift anything over 5-10 pounds for 4 weeks.• Return to your regular activities bit by bit over 6 weeks. Talk about any specific

concerns with your doctor. • Do not drive until after you have stopped taking opioid (pain) medication for at

least 24 hours or you have seen your doctor for your follow-up appointment.• Take lots of rest periods as necessary. Let your body be your guide. • If you need to fly within 6-8 weeks after your surgery, please speak to your

healthcare team.• Avoid leaning your head back sharply, as this puts extra tension on your

internal neck stitches.

Wound care• You may shower 3 days after your chest tube is removed. You may take a bath

1 week (7 days) after your chest tube is removed. Avoid hot tubs, jacuzzis, and saunas for 6 weeks. Soaking in a tub for long periods may slow the healing of your incision. Clean your incision with mild soapy water. Pat the incision area dry. Do not rub your incision. Do not use lotion or powder on your incision.

• You may notice swelling or bruising around the wound. This is normal and may continue for several weeks.

• Check the incision every day for increased redness, a bad smell from the incision sites, tenderness, drainage, or open areas. Tell your doctor if any of these happen.

• There may be a stitch at the chest tube site. This must be removed by your family doctor or at a walk-in clinic in 7-10 days.

• Wear loose clothing while the wound is still tender.

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Medication(s)• Take pain medication as needed, for example, before going to bed and before

activity. You should expect some pain for a length of time after discharge, but it should be manageable. If the pain is too much to handle, call your doctor.

• If you experience constipation from your pain medication, we encourage you to drink more liquids. Eat more of the cooked or canned fruits and vegetables allowed on your diet, and choose whole grain breads and cereals. If constipation continues, try a liquid form of fibre such as Metamucil®. A laxative or stool softener may be needed until your bowels are regular.

J-Tube care

If the J-Tube falls out, go to the nearest Emergency Department as soon as possible because the incision could close up.The J-Tube is usually removed when you no longer need it for feeding. This is usually at the first follow-up visit to your thoracic surgeon after discharge from hospital, but may be longer if needed.

Flush with 10 CCs of tap water twice a day and after each time medication is given through the J-Tube. If you are on well water, and have not recently had it checked for bacteria content, use bottled water for your flushes.

To flush the J-Tube:

1. Draw 10 CCs tap water into a syringe

2. Remove the cap on the end of the J-Tube

3. Insert the syringe into the J-Tube

4. Inject 10 CCs of tap water and remove the syringe

5. Re-insert the cap on the end of the J-Tube

A booklet is available on the unit for Home Tube Feeding (LC85-1211). The dietitian or nurse will go through the teaching with you and/or your family members.

After discharge, a home care nurse can help you and/or a family member with the care of your J-Tube if necessary (dressing around tube and flushing tube).

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Esophageal Soft DietWhen you start to eat again, you will start with a clear fluid diet for a day, move on to a full fluid diet the next day, and then to the Esophageal Soft Diet. We recommend that you follow the Esophageal Soft Diet for 6 weeks after your surgery.

The following guidelines will help you manage symptoms you may have after an esophagectomy.

To manage fullness (early satiety):1. Eat small meals more often; for example, eat 6 small meals per day instead

of 3 main meals. 2. Drink liquids on their own instead of with meals.

To control diarrhea:1. Eat only until you feel satisfied that you are full. 2. Avoid foods with a lot of sugar; e.g. ice cream, milkshakes, etc. 3. Avoid foods that are natural laxatives; e.g. prunes, figs, flax, and licorice. 4. Eat slowly, take small bites, and chew your food well. 5. Drink liquids on their own instead of with meals; e.g. 20-30 minutes after

meals. 6. If diarrhea becomes really bad, call your dietitian or your surgeon.

To control reflux:1. Stay sitting for 45 minutes after eating or drinking. 2. Avoid eating or drinking 2 hours before going to bed. 3. Do not lie flat when resting or sleeping. Raise the head of your bed or use

pillows.4. Eat smaller amounts of food more often throughout the day to avoid over-

filling your stomach. 5. Avoid spicy and acidic foods; e.g. black pepper, hot peppers, citrus fruits or

juices, and tomato-based products. 6. Avoid alcohol and smoking. 7. Limit caffeine intake (coffee, tea, chocolate).

To avoid weight loss:Weigh yourself weekly. If you are losing weight, call the dietitian who followed you during your hospital stay or who is following you in the community to learn how to increase your caloric intake.

25

Esophageal Soft Diet guidelinesThe foods in the following Esophageal Soft Diet guidelines should be soft and moist. Cook your foods thoroughly. Adding sauces or gravies to your food is recommended. Take small bites and chew well to turn food into a smooth paste or purée consistency in your mouth. Avoid eating very hot or very cold food.

Note: If your surgeon wants you to only have liquids and purées at first, follow the Step 1: Purée Diet for days, then move to Step 2: Esophageal Soft Diet.

Step 1: Purée DietHave only liquids and smooth puréed foods such as:

› Water, juice, milk. › Milkshakes. › Smooth yogurts, puddings. › Broth, strained, or blended soups. › Ice cream, sherbet, sorbet. › Jell-O® (soften Jell-O® to a liquid in your mouth before swallowing). › Carnation Breakfast Anytime®, Ensure® or Boost®-type drinks. › Store-bought bottled puréed meat, vegetables, and fruit (no chunks). › Campbell’s Trepuree® frozen puréed entrees, homemade strained puréed

foods. › Foods should be the consistency of smooth applesauce or pudding with no

chunks or strings. › Limit yourself to 1 cup (250 ml) per hour for the first 1-2 days, and eat

slowly. › Your dietitian can give you the booklet How to Purée Foods (LC85-0624). › Campbell’s Trepuree® Frozen Entrees are available to buy from the VON in

some communities. › Include 3-4 commercial or homemade (see recipes on page 28) high-protein

high-calorie drinks daily, such as Ensure®, Boost®, or Carnation Breakfast Anytime®.

› For extra calories, choose Ensure Plus® or Boost Plus Calories®.

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Step 2: Esophageal Soft Diet

Best choices Foods to avoid

Grain products

• Cooked cereal and dry cereal that softens easily with milk

• Pasta and soft, moist rice in soups and sauces

• Crushed crackers and pieces of bread with crusts off, soaked in soup

• Fresh “doughy” or crusty bread, muffins, biscuits, pancakes, waffles

• Granola, Shredded Wheat®• Breads and cereals containing

seeds, nuts, coconut, and dried fruit

Vegetables and fruit

• Soft, very well-cooked vegetables with skins removed, chopped fine and used in soups, sauces, or stews

• Soft, moist mashed or scalloped potatoes in gravy or sauce

• Canned, ground, or crushed tomatoes, tomato juice, tomato soup

• Minced yellow or green beans and minced peas in gravy or sauce

• Canned or cooked fruit with peels removed

• Ripe banana• Applesauce, apple blends

• Raw or stir-fried vegetables, salads, coleslaw

• Tough or stringy cooked vegetables (such as spinach, celery, whole peas, whole green and yellow beans, Brussels sprouts, stewed and diced tomatoes, asparagus, corn)

• Raw fruit (bananas are OK)• Pineapple, grapes, kiwi, grapefruit,

oranges, rhubarb, berries• Dried or candied fruit (raisins,

currants, dates)

Milk products

• Milk, smooth yogurt, pudding, ice cream, mousse, creamy cottage cheese, thin cheese sauce

• Stringy cooked cheese such as melted cheddar or mozzarella

• Hard cheese• Yogurt with nuts or granola

27

Best choices Foods to avoid

Meat and alternatives

• Minced tender meat, poultry, or boneless fish, always in gravy, sauce, or broth

• Scrambled, poached, or soft-boiled eggs, chopped and topped with melted margarine or sauce

• Well-cooked, tender legumes and lentils in soup or sauce (for example, soft baked beans)

• Dry, tough, or stringy meats• Bacon• Nuts and seeds• Hard-boiled and fried eggs• Peanut butter (unless blended in a

smoothie)

Other

• Nutritional drinks such as Ensure®, Boost®

• Milkshakes, Carnation Breakfast Anytime®

• Store-bought eggnog, sherbert, Jell-O®

• Popcorn, chips, tacos• Foods containing coconut, nuts,

seeds, or dried fruit• Pickles, olives• Gelatin-type candies (gum drops,

jelly beans)• Cake, pie, pastry

Note: Ask your dietitian if you should take a liquid or chewable multivitamin mineral supplement. Chew tablets completely and have a drink to help any particles go down.

28

High-Protein High-Calorie Drink Recipes

High-Protein Milk• 1 cup (250 ml) whole milk• ¼ cup (60 ml) skim milk powderAdd powder to milk. Mix until powder is mixed completely. Refrigerate.

Makes 1 serving.Energy: 260 caloriesProtein: 19 grams

Can be used: › As a beverage, in milkshakes › On cereal and cooked or puréed

fruit › In soups, puddings, cream

sauces, and mashed potatoes

High-Protein Milkshake• 1 cup (250 ml) whole milk• ½ cup (125 ml) plain ice cream or

frozen yogurt • ¼ cup (60 ml) skim milk powder• ½ cup (125 ml) fruit (try bananas or

peaches)Place ingredients in blender. Blend ingredients together until smooth. Refrigerate.

Makes 1 serving.Energy: 345 caloriesProtein: 22 grams

For safe use of homemade drinks1. Keep drinks refrigerated and throw out after 24 hours.

2. Do not keep drinks at room temperature for longer than 2 hours.

3. Do not add raw eggs to your blended drinks. Egg beaters® or Naturegg Break-Free™ egg substitutes can be used. These are found in the cold or frozen section at your local grocery store.

The clinical dietitian or diet technician will review the Esophageal Soft Diet with you and answer your diet-specific questions about one week after your surgery. If you still have questions, be sure to ask the clinical dietitian to visit again before you go home. You will receive a diet booklet with the dietitian’s phone number in case you have diet questions after you get home.

29

When to call for helpCall 911 any time you think you may need emergency care. For example, call if:• You passed out (fainted or lost consciousness). • You have a hard time breathing. • You have sudden chest pain and shortness of breath, or you cough up bright

red blood.

Call your doctor or 811 or seek medical care right away if: • You can’t keep fluids down. • You have a fever over 38 degrees C, increased trouble swallowing, or increased

nausea and vomiting.• You have trouble flushing the J-Tube or discharge from around the J-Tube.• You have loose stitches, or your incision comes open.• You have increased swelling in your legs.• Bright red blood soaks through the bandage over your incision.• You have signs of infection, such as:

› Increased pain, swelling, warmth, or redness › Bad smell from the incision sites › Red streaks leading from the incision › Pus draining from the incision › Swollen lymph nodes in your neck, armpits, or groins › A fever

• You cough up a lot more mucus than normal, or your mucus changes colour.Watch closely for changes in your health, and be sure to contact your doctor if you have any problems.

** Go immediately to the Emergency Department if the J-Tube falls out **For 24/7 nurse advice and general health information, call Health Link at 811.

We hope this book has helped to guide and support you. The information comes from team members and patients like yourself. Your suggestions are important.

30

ResourcesThe diagnosis and treatment of esophageal cancer may have a major impact on you and the people close to you. The disease may affect your physical, emotional, social, spiritual, and practical needs. As a result, you may experience many issues. There are many resources available within the hospital and community, and on the Internet to help you and your family.

Publications• What You Really Need to Know About Cancer: A Comprehensive Guide for

Patients and Their Families. R. Buckman, Key Porter, 1995.• Everybody’s Guide to Cancer Therapy: How Cancer is Diagnosed, Treated, and

Managed Day to Day. M. Dollinger, E.H. Rosenbaum, G. Cable. Sommerville House, 1995.

• Coping With Cancer Magazine › Phone: 615-790-2400 › E-mail: [email protected] › http://copingmag.com/cwc

Telephone › Canadian Cancer Society: 1-888-939-3333

Online cancer resources › Cancer Care Nova Scotia: www.cancercare.ns.ca › Cancer Care Nova Scotia – Support group info: www.cancercare.ns.ca/en/

home/patientsfamilies/livingwithcancer/support.aspx › Canadian Cancer Society/National Cancer Institute: www.cancer.ca › Cancer Care Ontario: www.cancercare.on.ca › CancerNet (American Society of Clinical Oncology): www.cancer.net › Health Canada: www.hc-sc.gc.ca/index-eng.php › Cancer Care Inc.: www.cancercare.org › OncoLink (Ambramson Cancer Center of the University of Pennsylvania):

www.oncolink.org › Thoracic Procedures & Surgery: The University Health Network: www.uhn.

ca/PatientsFamilies/Health_Information/Health_Topics/Pages/thoracic_surgery.aspx

› Lung Cancer Canada: www.lungcancercanada.ca

Questions for your healthcare team:

Looking for more health information?This pamphlet and all our active patient pamphlets are searchable here: http://bit.ly/NSHApamphlets

Contact your local public library for books, videos, magazines, and other resources. For more information go to http://library.novascotia.ca

Nova Scotia Health Authority promotes a smoke-free, vape-free, and scent-free environment.Please do not use perfumed products. Thank you!

Nova Scotia Health Authoritywww.nshealth.ca

Adapted by: Thoracic Clinic Healthcare Staff ©Illustrations by: LifeART Super Anatomy 1, 3, & 5 Images, Copyright © 1994, TechPool Studios Corp. USA; The Ottawa Hospital Printing Services; Jennifer Strong

Designed by: Nova Scotia Health Authority, Central Zone Patient Education TeamPrinted by: Dalhousie University Print Centre

The information in this brochure is for informational and educational purposes only.The information is not intended to be and does not constitute healthcare or medical advice.

If you have any questions, please ask your healthcare provider.

WF85-1633 Created July 2016The information in this pamphlet is to be updated every 3 years or as needed.

Thoracic Clinic Healthcare Staff © Thoracic Clinic Healthcare Staff © LifeART Super Anatomy 1, 3, & 5 Images, Copyright © 1994, TechPool Studios Corp. USA; The Ottawa Hospital Printing Services; Jennifer Strong LifeART Super Anatomy 1, 3, & 5 Images, Copyright © 1994, TechPool Studios Corp. USA; The Ottawa Hospital Printing Services; Jennifer Strong

Nova Scotia Health Authority, Central Zone Patient Education TeamNova Scotia Health Authority, Central Zone Patient Education Team Dalhousie University Print Centre Dalhousie University Print Centre

The information in this brochure is for informational and educational purposes only.The information in this brochure is for informational and educational purposes only.The information is not intended to be and does not constitute healthcare or medical advice.The information is not intended to be and does not constitute healthcare or medical advice.

If you have any questions, please ask your healthcare provider.If you have any questions, please ask your healthcare provider.

The information in this pamphlet is to be updated every 3 years or as needed.The information in this pamphlet is to be updated every 3 years or as needed.WF85-1633 Created July 2016WF85-1633 Created July 2016The information in this pamphlet is to be updated every 3 years or as needed.The information in this pamphlet is to be updated every 3 years or as needed.

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