Postoperative Care

The aftercare of a patient who has been subjected to esophagectomy is almost as important as the operation itself. During the operative procedure, the patient will have received one to three units of whole blood. Occasionally a fourth unit may be needed, but it should be remembered that it is easy to overload these elderly people with too much intravenous fluid and therefore the transfusions should be administered at a slow rate of speed. Prior to operation, the patient has been instructed to avoid any swallowing during his waking hours until the day for swallowing liquids arrives. Over the years, I have endeavored to ascertain the optimum time to start the swallowing of liquids, based mainly on microscopic sections of the rate and degree of repair at the site of the anastomosis. One must not disregard the powerful contracting force of the external longitudinal musculature of the esophagus during deglutition. In the presence of a poorly constructed anastomosis, especially under tension, disruption of one or more sutures is not difficult to visualize. By and large, in the average patient with a satisfactory anastomosis, swallowing can be started on the fourth postoperative day. Of course, the local changes at the site of repair must ever be kept in mind by the surgeon to guide him in deciding when swallowing of liquids may be started. Naturally, the insensible deglutition during sleep cannot be avoided, but the regime which I will detail has been developed by trial and error and has been found satisfactory.

During the first six postoperative days, intravenous fluids are administered continuously at the rate of 2,000 to 2,500 ml in 24 hours. Skin turgor, urine output, loss by sweating, and frequently blood electrolyte determinations will guide the surgeon in deciding whether the total amount should be increased or decreased. Other factors which influence these decisions are the age of the patient, status of the myocardium, kidney function, and pulmonary complications. In the main, intravenous fluids consist of normal saline in glucose alternating with glucose in distilled water, each bottle containing the necessary vitamins and potassium. This must be watched carefully from day to day. During the immediate postoperative period, oxygen is administered by the nasal route. The patients are encouraged to cough, and regular breathing exercises are encouraged. Occassionally, bronchoscopy or even tracheostomy may be necessary to aspirate viscid bronchial secretions.

During the first 24 hours, the intercostal tube drains between 200 and 400 ml of sanguinous fluid. Thereafter the amount of drainage decreases rapidly. I prefer to leave this tube in place until the sixth or seventh day because the character of the fluid will indicate the presence of a leak should one occur. After that time, the possibility of a leak is remote. While I strongly disapprove of routine antibiotic therapy in general, I am sure that most everyone will agree that such therapy is particularly indicated after this operation, especially to obviate possible pulmonary complications. Therefore, penicillin and streptomycin or one of the broad-spectrum drugs are administered for the first four days.

The oral intake regime which we use is as follows:

  • 4th day: 4 ml water every 15 to 30 minutes
  • 5th day: 8 ml water and/or tea every 15 to 30 minutes
  • 6th day: 15 ml water, tea, milk or Jell-O every 30 minutes
  • 7th day: 1 to 2 ounces water, tea, milk, Jell-O, custard, cereal, ice cream as tolerated
  • 8th day: add soft boiled eggs and pureed vegetables
  • 9th day: regular soft diet including scraped beef and chicken until the14th day when the food intake may be liberalized.

The patient is instructed to eat always in the sitting position, avoid swallowing large boluses of meat and bread, and to avoid lying down after eating. To prevent or minimize regurgitation of gastric contents, the patient should always sleep on two or three pillows. In our group of long-term survivors, the complaint of night regurgitation is seldom heard. They have learned how to avoid it.

 

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