Esophageal Cancer

Welcome to Vanderbilt University Medical Center and the Department of Thoracic Surgery. We appreciate the trust that you have given us to provide the best and most optimal treatment for you. Our thoracic surgeons are dedicated to the diagnosis and treatment of tumors of the esophagus and chest with over 50 years of collective experience in the management of esophageal cancer. Our goal is to give you exceptional care using a multidisciplinary approach that considers every aspect of therapy. The team consists of thoracic surgeons, medical oncologists, radiation oncologists, residents, nurses, nurse practitioners, medical students, case managers, physical therapists and dieticians.

The esophagus is a tubular structure that begins within the neck, traverses the middle chest and enters the stomach below the diaphragm. Cancer occurs when the cells within the lining of the esophagus change and grow in an uncontrolled fashion. The most common symptom is difficulty swallowing food because of the blockage caused by the tumor. Weight and appetite loss are also common symptoms.

Several tests are used to determine the cause of symptoms. As an initial screening study to assess the anatomy of the esophagus and to look for possible causes for symptoms, a barium swallow is performed. Liquid barium is ingested to coat the inner lining of the esophagus which allows X-ray evaluation of structural and mechanical problems. Depending on the results, further tests are performed.

Commonly endoscopy is performed to further assess the esophagus. This involves the use of a lighted scope through which the physician can visually inspect the inner lining of the esophagus and stomach. During this procedure, small biopsies of the tissues are taken to view under the microscope. This analysis is the definitive diagnostic test.

Staging of Esophogeal Cancer
The extent of disease or stage is an essential component to the management of esophageal cancer. It not only helps to determine the best method of treatment but also helps to predict prognosis. Staging uses a system known at the TNM system to define the extent of disease.

•T -refers to the size of the tumor
•N -refers to the involvement of nearby lymph nodes
•M -indicates whether the cancer has spread (metastasized) to other organs or distant lymph nodes.
The TNM system is used to assign a stage ranging from 0 through IV to the cancer. The higher the number, the more the cancer has spread.

Staging Procedures
The information obtained from the X-rays and additional procedures provide further information needed to determine the exact TNM stage.

Esophageal Ultrasonography (EUS)
Using endoscopy sound waves penetrate the esophageal wall and generate images of the affected area of the esophagus. This procedure helps to determine the extent of invasion by the tumor.

CT Scan
Computed Tomography also known as a CT scan uses a computer to create a three-dimensional scan from a series of x-ray images.  A CT scan provides much more detail of the tumor and adjacent anatomic structures.

PET scan
Positron Emission Tomography (PET) traces the way the body cells accumulate glucose. Tumors tend to take up sugar. When an area in the body illuminates on a PET scan, it is due to the uptake of radioactive sugar. Abnormal areas of uptake are suggestive of malignant disease.

The determination of treatment is directly related to the stage of disease. There are three standard options for treatment of cancer of the esophagus: surgery, chemotherapy and radiation therapy. They can be used alone or in combination. The treatment that is most appropriate will be offered. Factors that must be considered in choosing a treatment plan include the size and location of the tumor, involvement of surrounding tissue, spread to other parts of your body and your overall health. For patients who have disease confined to one area and are operative candidates, surgery to remove the esophagus is the treatment of choice. For patients who have disease outside the confines of the esophagus and for patients who have prohibitive concurrent illnesses, chemotherapy and radiation therapy are the most appropriate choices for treatment. Frequently, combinations of treatment are selected.

Chemotherapy is the use of cancer-killing drugs. They are typically administered intravenously (IV) and target cancer cells throughout the body. Combinations of these drugs are often used over several weeks or months. 

Radiation Therapy
Radiation therapy is the use of high-energy waves aimed directly at the tumor. It is usually used in combination with chemotherapy. The intent of radiation is to minimize or ablate the tumor prior to surgery or in lieu of surgery if the patient is not an operative candidate.

Surgery is performed to remove the tumor and adjacent lymph nodes with a margin of cancer free tissue around the tumor. The second goal of surgery is to reestablish anatomic continuity between the mouth and stomach that allows the patient to eat and swallow once again. After the esophagus is removed, the remaining stomach is brought up into the chest and attached to the remaining esophagus in the neck or upper chest. Sometimes a portion of the large intestine is removed and used to replace the esophagus that was removed.

Surgical Techniques
There are several methods to perform the operation. These techniques and the selected technique for a particular patient are discussed with the thoracic surgeon. Several factors are considered. The overall condition of the patient, size of the tumor, location of the tumor, and involvement of tissue and organs near the tumor will be important factors in determining how the operation is done. The three most commonly used approaches are transhiatal, transthoracic, and thoracoabdominal.

Transhiatal -- The transhiatal approach uses an abdominal incision and a neck (cervical) incision. The abdominal portion of the operation involves freeing the stomach and esophagus from adjacent structures and removing lymph nodes in the area. The cervical incision is made to visualize and mobilize the upper portion of the esophagus within the neck. The lower esophagus is removed, a tube is constructed out of the stomach, and the tubed stomach is pulled up through the chest and attached to the remaining portion of the esophagus within the neck.
Transthoracic -- A transthoracic approach involves an incision in the abdomen and a separate incision in either the right or left chest. The mid and lower portions of the esophagus as well as the upper portion of the stomach are removed through the abdominal incision. Nearby lymph nodes are also removed. Then a chest incision is made and the remaining part of the esophagus is removed. The stomach is then created into a tube, pulled up and attached to the remaining portion of the upper esophagus within the chest. This approach is also used when a third incision is used to reattach the tubed stomach to the remaining esophagus within the neck.
Thoracoabdominal -- In this approach one long incision is used. It extends across the chest and into the abdomen. The esophagus and part of the stomach are removed. Their ends are put back together in either the neck or the chest.

Preoperative Planning
During your first visit to the Thoracic Surgery Clinic, you will meet several members of our team including your thoracic surgeon. It is very important that you bring all x-rays, CT scans, reports, and letters from other physicians or hospitals. A medical history will be taken and a physical examination will be performed. The surgeon will discuss his findings and give his recommendations. Together you and your surgeon will develop a plan of how to proceed based on his or her recommendations and your wishes. The thoracic surgery administrative and scheduling assistant will schedule any other tests or procedures that are needed. Most tests will be done here at VUMC. Whenever possible, if tests can be done close to home, they will be scheduled as such. After any additional tests and/or procedures are completed, you will return for another visit with the thoracic surgeon. At this visit, he will summarize all the findings and make further recommendations. If surgery is planned, the details of the recommended operation will be discussed. If chemotherapy and/or radiation therapy is indicated before surgery, this will be arranged. Any questions and/or concerns can be addressed at any time during these visits.

If surgery is scheduled, pre-admission testing will be scheduled at VUMC several days prior to the operation date. This is called VPEC. You should plan on being here for several hours. Please remember to eat breakfast and take all of your usual medications on that day, unless you have been told otherwise. Comfortable clothing and shoes are advised. It is helpful to bring an up-to-date list of all your medications and dosages for the VPEC personnel. You will meet with one of the anesthesiologists to plan your anesthesia care during surgery. Any necessary blood tests, electrocardiograms, or other tests that have not yet been done will be performed during this pre-admission visit.

In the days prior to surgery and in preparation for surgery, we have several recommendations:
-  Walk as much as possible to maintain the best possible conditioning.
-  Continue to maintain your nutritional status and weight, using dietary supplements if necessary. Please contact your thoracic surgeon if swallowing difficulties prevent the ingestion of required daily calories.
-  The day prior to surgery, take only a clear liquid diet. Enemas may also be prescribed by your surgeon.
-  No smoking. Smoking will significantly increase the postoperative risk of pneumonia and is a mandatory requirement prior to surgery.
-  Stop or limit consumption as much as possible.

Postoperative Care
The day of surgery, you will arrive at the admissions office and will be taken to the Pre-operative Holding Room. The anesthesia team and the operating room nurses will interview you once again. The Acute Pain Service (APS) will talk with you about postoperative pain management. Two methods are used: epidural analgesia and patient controlled analgesia. An epidural catheter is a small tube that is inserted into your back by the anesthesiologist. It is attached to a small device that delivers pain medication. While it is in place, you should have effective pain control and can be adjusted to your needs. Patient controlled analgesia (PCA) is another effective method used for managing pain. It is a device attached to an intravenous line (IV) in your arm. It has a small button that you can push to give yourself pain medication as you need. It is programmed so you receive an appropriate dose. In most circumstances, an epidural catheter is placed and is inserted in the Holding Room.

In the operating room, you are given anesthesia and a tube is placed within your airway for the duration of the operation. A tube is also placed in your nose and passed into your stomach for draining fluid and air. The operation is usually performed over a four to six hour period, though it may take longer or shorter depending on the degree of scarring and the intricacies of the anatomy.

Following your surgery, you will be transferred to the "Post Anesthesia Care Unit." This is a recovery area near the operating room where you will be connected to several monitoring devices. Members of the team will watch your condition closely as you awaken from anesthesia. When you have recovered sufficiently, you will be transferred to a bed in the intensive care unit. Nurses in these units are specialists in caring for cardiothoracic surgery patients who have had esophageal surgery. When you fully awaken, you may have several tubes and wires in place:
-   IV tubes to provide intravenous fluids
-   An oxygen mask or nasal oxygen
-   Heart monitoring equipment with EKG leads
-   Tubes from the rib cage to drain the chest cavity
-   Urinary catheter (foley catheter) draining the bladder
-   Jejunostomy tube from the abdomen
-   Drainage tube from the neck to drain the neck incision
-   Nasal tube (nasogastric tube) draining the stomach

Each of these devices and tubes serves a very important purpose in your recovery. They are removed as you progress through the postoperative period.

Key Elements to a Successful Postoperative Recovery

Your physicians and nurses will make every effort to monitor you closely for specific benchmarks of progress each day. The duration of the hospital stay depends on a host of issues that are not entirely predictable. But the combination of attentive care and patient initiative will facilitate an expeditious hospital course. There are several key elements that you can do to speed your recovery while reducing a complicated postoperative course:

-   Ambulation: Walking and activity will aid in clearing secretions from your lungs, help your circulation, and help you to regain muscle strength. You will be sitting up in bed and possibly getting out of bed soon after your surgery. You will progress to sitting in a chair and walking to the bathroom with the assistance of your nurse. A physical therapist will take you for your first walk and you will then progress to walking several times each day.
-   Deep breathing exercises: The incentive spirometer is an instrument that encourages you to take deep breaths. It will be given to you during the perioperative period. It is important that you use it several times an hour (at least 10) for several days after your surgery. Deep breathing and coughing exercises after surgery help to expand the lung and clear the lung of mucous that can be retained and cause pneumonia.
-   Pain Management:  Insuring adequate pain control is key to a smooth recovery. Though the incisional discomfort can be significantly relieved with analgesics to allow comfortable breathing and activity, it will not be completely removed. The various pain management modalities were described earlier and include the epidural catheter, the patient controlled anesthesia (PCA), medication administered by injection, and medication taken by mouth. You will receive pain medication when necessary and as your condition allows. You will be asked to rate your pain using a pain scale (see below). You will assign a number to your pain and this will help members of your health care team understand how much pain you are experiencing.

                                              0-10 NUMERIC PAIN INTENSITY SCORE:

No Pain                                                                Moderate Pain                                                  Worst Pain

Postoperative Diet
You will not be allowed to take anything by mouth for several days after your surgery, except for occasional ice chips. This is to allow time for healing. When you no longer have a nasogastric tube and when your surgeon determines it is safe, you will begin to take small sips of clear liquids. Pureed foods and then soft foods will follow this. Patients will go home with a jejunostomy tube to continue this form of supplemental feeding. If you are not able to take in adequate nutrition by mouth following your surgery, we will ask that you continue tube feedings at home in addition to eating what you can by mouth. Because good nutrition is vital to healing and your overall recovery, tube feedings may be necessary for a time until you are able to eat enough.

Your diet will be advanced to pureed and then soft foods. This phase often occurs while you are in the hospital. A post-esophagectomy diet will be discussed by the dietician who will visit with you during your recovery in the hospital.

Key Elements to Dietary Management

To control feeling full, eat small, frequent meals 5-6 times a day. You do not have the capacity for large meals so smaller meals are necessary. It will be several months before you will be able to eat a full meal. Drink most of your liquids between meals. To avoid any swallowing difficulties, eat slowly and chew your food well. When taking meats and bread, chop or cut them into small pieces and chew them well before swallowing. Eat in an upright position and remain sitting or walk for at least 30 minutes after eating prior to assuming a recumbent position. The stomach must empty by gravity. Lying flat soon after eating is counterproductive to stomach emptying and may cause aspiration. Eat dinner at least 2 hours before going to bed at night. Be aware that foods such as beans, broccoli, cabbage, peas, and onions may cause gas. Over-the-counter anti-gas products can be helpful. Foods that are rich in sugar and foods that are high in milk content can cause diarrhea. If diarrhea is a problem, speak with your surgeon. Imodium or Lomotil taken 30 minutes prior to your meal are helpful in preventing diarrhea. If constipation occurs, sometimes a problem with pain medication usage, can be avoided by using a stool softener, by eating a high fiber diet and by drinking adequate quantities of fluid. Protein and calories are important to aid in healing. Avoid foods that are high in calories but of little nutritional value such as sweets, candy, chips, etc. Adhere to a diet that includes fruits, vegetables and whole grains. Weigh yourself weekly. If you are losing weight, then eat more often or eat more food.

Tube feedings may be continued when you go home to supplement your nutrition. Some patients will not require tube feedings. They will be decreased and eventually discontinued as your appetite improves and your oral intake increases. If your weight is stable and you are taking adequate calories by mouth, your tube feedings will be stopped.

Flush your tube as you have been instructed as well as after medication usage through the tube. Do not crush pills and give through your tube unless your care providers have given their approval. Pills can clog the tube, resulting in the need to have it replaced. If the tube becomes dislodged or falls out, it is important that you go immediately to the nearest emergency room to have it replaced.

Exercise is very important to your recovery. Wear loose and comfortable clothing. Walk daily at a pace that is comfortable for you. Begin with short distances and do a little more each day as your body tolerates. Walk outside if weather permits. You may climb stairs as tolerated. Alternate your activity with short rest periods. You should set the goal of walking, cumulatively, at least 1-2 miles each day by 4-6 weeks after your surgery. Avoid lifting objects heavier than a gallon of milk until your surgeon permits. You can ride in a car at any time. You may engage in activities out of the home as your activity permits. Do not drive for at least 4 weeks, or until your surgeon permits.

Incision Care
Keep your incisions clean and dry. If they are still draining you may cover with a small gauze dressing. If you go home with sutures or staples, they will be removed at your follow up visit with the surgeon. If you have steri-strips (small pieces of white paper tape over the incision), they will fall off or may be removed within 2 weeks after returning home. Do not use lotions, salves, creams or ointments on your incisions. You may take a shower at any time. Pat dry the incisions afterwards. Do not soak in a bathtub or hot tub.

Pain Medications
When you are discharged, you will receive a prescription for pain medication. This will be provided in either liquid or pill form. During the first couple of weeks, you may find it necessary to take pain medication fairly regularly, every 4 to 6 hours. You should try to gradually decrease the pain medication as your pain subsides. You can then switch to milder pain medications such as Tylenol or ibuprofen unless you have been instructed to avoid either of these products.

Prehospitalization Medications
Resume your usual medications unless instructed otherwise. If you were already taking pain medication prior to your admission and you are given a prescription for a new pain medication when you are discharged, do not take both unless you have discussed it with your health care provider.

You will be given the clearance to return to work when you and physician agree you are ready. This will be discussed during your follow up visit. It will vary, depending upon your employment.

Return Appointment
Prior to your departure from the hospital, a follow up appointment will be made with your thoracic surgeon approximately two to four weeks after you are discharged from the hospital. If you need to change your appointment, please call the Thoracic Surgery Clinic at (615) 322-0064, Option 4.