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Ivor Lewis Oesophagogastrectomy

Lisa Humphreys

Abstract

Lisa Humphreys is a Registered Nurse in the Intensive Therapy Unit at St. Vincent's Hospital, Sydney.

This is a case study of lack, a 71 year old man diagnosed with adenocarcinoma of the oesophagus.

Jack underwent surgery, and Ivor Lewis Oesophagogastrectomy and this case study follows Jack's progress, outlining the nursing care he received while in the Intensive Therapy Unit.

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When the leaves turn red upon the vine
or the pink and gold of sunset
turn to grey -
when the moon is on the wane
and the party's almost over,
don't cry for things
too beautiful to last, my love -
tomorrow is the beginning
of a brand new day.
(Witcombe, 1989)

The above quote inspired in me the zest for which Jack (a pseudonym) displayed for life and the time he had with his loved ones and the time he looked forward to on leaving hospital.

Jack, a 71 year old retired gentleman was admitted to St. Vincent's Hospital on the 4th May 1993 with a diagnosis of adenocarcinoma of the oesophagus.

Adenocarcinoma of the oesophagus has distressing symptoms for the patient. Depending on the stage of the tumour, treatment is often palliative and can be in the form of surgical resection. Jack required such an operation, the procedure performed was an Ivor-Lewis Oesophagogastretomy.

Jack was a heavy smoker for twenty years, on average one to two packets per day, and drank heavily (the amount per day unknown), but ceased both thirty years ago. There is a strong relationship between smoking and drinking and the development of oesophageal cancer as noted by Tuyns, (1983, cited in Frank-Stromberg, 1989: 59).

The symptomatic onset of Jack's disease began in June 1991 when he noticed an increase in belching and dysphagia. "Difficulty in swallowing (dysphagia), which is an initial symptom of oesophageal cancer, does not occur until at least sixty percent of oesophageal circumference is infiltrated by cancer. Dysphagia usually begins with solid food and then gradually progresses to include semi-solids and liquids." (Frank-Stromberg, 1989: 58).

The dysphagia became progressively worse requiring Jack to undergo an endoscopy and dilation of his oesophagus. A biopsy of the tumour was taken at the same time and found to be adenocarcinoma. Adenocarcinoma accounts for about five percent of oesophageal tumours (Andreoli et al., 1990: 297).

Little relief was obtained from the dilation and he was recommended for aggressive chemotherapy in conjunction with radiotherapy. However, by the beginning of 1993, Jack was experiencing constant belching after meals with increasing dysphagia. His food intake was altered to soft foods with little effect and the dysphagia continued to increase.

Surgical resection of the oesophageal tumour was the next option available to alleviate the symptoms. Jack recognized that surgery was required and felt it would enable him a better quality of life and more time with his wife.

An Ivor-Lewis Oesophagogastrectomy involves excising the oesophageal tumour and re-anastamosing the stomach and the oesophagus (Hardy, 1983: 488). As the oesophagus is accessed via a thoracotomy and deflation of the lung, patients are routinely nursed in Intensive Care for respiratory maintenance and observation. Two thoracic drains, (intercostal catheters), are placed in the pleural cavity to drain air and fluid/blood to enable the lung to re-inflate.

The complications specific to an Ivor-Lewis Oesophagogastrectomy include:

  1. Haemorrhage into the mediastinum
  2. Pain from nerve damage and resection of the sixth rib.
  3. Collapse of the right lung after deflation intra-operatively.
  4. Chylothorax - "the presence of effused chyle in the pleural cavity" (Dorland, 1982: 149) - when the thoracic duct is nicked intra-operatively.
  5. Dumping Syndrome, when after eating there is a rapid movement of gastric contents into the upper intestinal tract (Schwartz, 1989: 1168).

Survival after the operation with no complications depends on what stage the tumour was when discovered and when treatment was commenced.

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Post Operative Management

On admission to Intensive Care Jack had in situ:-

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Nursing Objective 1: Nursing Management in Intensive Care

The nursing care in the Intensive Care Unit encompasses a holistic approach as outlined in the following objectives:

1. Promote optimal airway and ventilation management

Rationale

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Expected Outcomes

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Nursing interventions

  1. One hourly chest auscultation and record effort, rate characteristics and symmetrical chest expansion.
  2. While ventilated, record one hourly respiratory rate, percent of inspired air, tidal volume, expired minute volume and level of peep.
  3. One hourly recording of vital signs.
  4. Monitor arterial blood gases six hourly with increased frequency while weaning. Alert doctor if there are changes outside normal parameters.
  5. Check endotracheal tube and auscalate one hourly for cuff leaks. Report immediately if the cuff seal is inadequate.
  6. Monitor daily and P.R.N. chest X-rays -observe for abnormalities/ changes and tube positions including:
    1. Central venous line - in superior vena cava in mid-line with aortic notch.
    2. Naso-gastric tube - in stomach, in this case in the thoracic cavity.
    3. Intercostal catheters - in thoracic cavity, one apical, one basal.
  7. One hourly monitoring of oxygen saturation via pulse oximeter. Alter finger/ear lobe two hourly to alleviate the potential for pressure areas.
  8. Position patient at thirty degrees or greater if tolerated, for optimal chest expansion and gas exchange.
  9. Ensure gas delivered to patient is humidified. Maintain water levels in humidifier bath.
  10. One hourly suction to clear sputum. Note: Not if patient is in pulmonary oedema. Record sputum type and amount.
  11. Two hourly turning and positioning to allow for postural drainage and prevention of pressure areas.
  12. Care of mechanical ventilator as per unit protocol.
  13. In a ventilator crisis take patient immediately off machine and hand ventilate with black bag. Call for medical assistance if required.
  14. Maintain accurate fluid balance chart. 15. Record one hourly air, swing and drainage in intercostal catheters. Report if drainage is greater than one hundred millilitres an hour. If drainage ceases, check for tubing obstruction. Report excessive bubbling - indicative of a large air leak.
  15. Ensure medical staff are aware of intention to extubate and are available if required.
  16. Check for gag/swallow reflex post extubation. Patient to remain nil by mouth for four hours after extubation in case there is a need to re-intubate.
  17. Observe for signs of respiratory distress: harsh laboured breathing, decrease in oxygen saturation, sweating, tachycardia, dyspnoea, cyanosis, altered mental state. Report immediately.
  18. Encourage deep breathing and coughing exercises hourly. Participate in physiotherapy.
  19. Observe cough, type and amount of secretions and record.
  20. Administer saline nebulisers as ordered. When the patient is intubated and ventilated ensure a minimum intermittent mandatory ventilation rate of four breaths per minute in order to nebulise the saline while on the BIRD ventilator.
  21. Administer the rate and mode of oxygen as ordered by doctor.
  22. Explain all procedures to patient prior to commencing them. Maintain a calm approach.
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Participate in Observed Outcomes

Day 1

Jack was connected to a BIRD ventilator and commenced on an I.M.V. (Intermittent Mandatory Ventilation) of eight breaths by a Tidal Volume (the volume of air that is moved in and out of the lungs with normal respiration) of nine hundred millilitres. The inspired air delivered to the patient was forty percent.

Arterial blood gases were taken to monitor acid base balance which can be controlled in this case by respiratory rate. Initial results showed respiratory alkalosis so the IMV rate was decreased to elevate the carbon dioxide level.

Arterial blood gases performed later reflected a correction of the alkalosis.

Chest drains are a normal part of thoracic surgery and are required to drain fluid/air from the pleural site. This ensures adequate re-inflation of the lung so that adequate ventilation can be achieved. Both drains were connected to low wall suction. This system draws atmospheric air into the under-water drainage system creating a negative pressure.

On physical examination air entry and bronchial sounds were decreased in the right lung with audible course crackles. A chest X-ray was ordered and used as a base-line indication of abnormalities and a measurement of hydration.

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Day 2

Spontaneously starting to breathe up himself, the IMV rate was decreased to four breaths a minute, titrated to the arterial blood gas and pulse oximetry results. By the afternoon Jack was spontaneously breathing. He was extubated with great success. Following extubation a chest X-ray was ordered. This showed fluid overload. Jack's central venous pressure by this stage was + 5cm H2O. Medical staff ordered a decrease in the intravenous hydration fluid rate, thereby preventing further overload.

On auscultation, bilateral crackles were audible in the lungs. Saline nebulisers were ordered to humidify and help loosen secretions so they could be expectorated. Two litres of oxygen via nasal prongs was ordered. Arterial blood gases and pulse oximetry remained within normal limits on this setting.

Overnight Jack was coughing up copious amounts of sputum and was ordered frequent physiotherapy to assist.

Day 3

No drainage or air bubbling in the apical chest drain, indicated the lung was well expanded at the top. It was decided to remove this drain.

Day 4

Minimal drainage from the basal chest drain.

Day 5

The basal chest drain was removed.

Jack was alert and orientated to time, place and person. That morning Jack was transferred to the gastroenterology ward.

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Nursing Objective 2: Promote cardiovascular stability and management.

Rationale

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Expected Outcomes

The patient will maintain optimal cardiovascular output as evidenced by;

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Nursing Interventions

  1. Establish and monitor electrical cardiogram and vital signs one hourly and more frequently if required, document.
  2. Obtain four hourly rhythm strips and capture arrythmias where possible. Report abnormalities immediately.
  3. Care of haemodynamic monitoring as per unit protocol. Zero arterial and central venous pressure transducers at beginning of shift and there after when lines interrupted.
  4. Monitor and document haemodynamic parameters: central venous pressure four hourly at thirty degrees.
  5. Perform post surgical and post arrythmias electrical cardiogram. Report changes immediately.
  6. Assess patients peripheral perfusion at beginning of shift and continuously - colour, pulses present, capillary return.
  7. Assess continuously patients mental state.
  8. Maintain accurate fluid balance chart.
  9. Maintain oxygen and carbon dioxide levels as ordered by doctor.
  10. Monitor oxygen saturation via pulse oximeter.
  11. Measure size and fit thrombo-embolytic (TED) stockings.
  12. Apply calf compressors to legs and ensure proper workings of equipment.
  13. Administer intravenous fluids and drugs as ordered by doctor. Discard fluids running more than twenty four hours and obtain new intravenous fluid orders.
  14. Explain all procedures to patient prior to commencement.
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Observed Outcomes

Day 1

Jack was connected to a cardiac monitor to record blood pressure and arrythmias. He was hypertensive, 180/100, and in sinus rhythm on return to ITU. The hypertension was not treated. Instead it was decided to sedate Jack overnight, keep him pain-free, comfortable and provide adequate ventilation.

The central venous catheter (C.V.C.), was used for: Venous access; administration of intravenous hydration fluids; drug therapy administration; as well as the measurement of central venous pressure.

Routinely after any surgical operation an electrical cardiogram (E.C.G.) is performed. This ECG is then compared with the pre-operative one to give an indication of cardiac conduction function and any changes that may have occurred during surgery. Jack's ECG was normal.

TED stockings and calf compressors were also applied. Used in conjunction with one another they are excellent in producing a milking action which empties the lower leg veins, increases the blood flow in the femoral veins, thereby preventing stasis of blood and decreasing the risk of thrombosis.

An indwelling catheter was in place and hourly measures were taken, giving an indication of renal perfusion. Overnight jack's urine output decreased to less than thirty millilitres an hour for several hours and his blood pressure decreased to a hypotensive state of 90/60. The central venous pressure recorded -4cmH2O, which indicated hypovolaemia. A fluid challenge of one thousand millilitres of Normal Serum Albumin (N.S.A.) was administered.

Day 2

Jack remained normotensive with a good urine output. It was noted his albumin level was low at 27g/L (normal 36-47g/L), and to increase this, five hundred millilitres of Normal Serum Albumin was administered intravenously.

Day 5

The central venous line remained in situ for the continuation of total parenteral nutrition.

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Nursing Objective 3: Promote fluid and electrolyte, nutritional and gastro-intestinal stability.

Rationale

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Expected Outcome

Patient's fluid and electrolyte balance, nutritional requirements and gastro-intestinal activity will be maintained at an optimal level as evidenced by: [top]

Nursing intervention

  1. Maintain and record strict fluid balance chart.
  2. Listen for, record and report bowel sounds six hourly.
  3. Aspirate naso-gastric tube two hourly for first twelve hours, then six hourly. Test gastric pH with each aspiration. Maintain naso-gastric tube on straight drainage.
  4. Record blood sugar levels six hourly. Report any levels outside normal range (3-8mmol)
  5. Monitor urea and electrolytes continuously. Report any abnormalities. Administer supplements as prescribed.
  6. Note, record and report any arrythmias.
  7. Care of Total Parental Nutrition infusion as per unit protocol.
  8. Discard Total Parental Nutrition infusion if greater than twenty four hours administration time.
  9. Administer insulin if required for unstable blood sugar levels.
  10. Administer intravenous vitamins as ordered by doctor.
  11. Observe oral mucosa and skin turgor six hourly.
  12. Explain all procedures to patient prior to commencement.
  13. Administer sucralfate via the naso-gastric tube six hourly as ordered by medical staff.
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Observed Outcomes

Day 1

The naso-gastric tube was connected to a straight drainage bag, and two hourly aspirations were commenced. This was to ensure no accumulation of gastric fluids in the stomach while gut peristalsis was inactive, hence decreasing the possibility of a paralytic ilcus. On examination Jack's abdomen was tense and no bowel sounds were audible.

The medical staff ordered vitamin supplement as Jack had been fasting and would not return to diet for some days. Vitamins are essential for normal body function. Those ordered were intravenous folic acid and Intravite.

Bloods were collected from an arterial line. The arterial line placed in the radial artery provides immediate arterial access without causing trauma to the patient every time a blood sample is required. It also enables arterial waveform and blood pressure to be monitored.

The blood tests ordered were urea and electrolytes, blood sugar level, full blood count, blood coagulation times, liver function tests, calcium, magnesium and albumin levels. There was some concern that Jack might require a blood transfusion to increase his haemoglobin level. However with a result of 13.1g/dl (11.5-16.0g/dl normal range) no blood was required.

Day 2

No nasogastric aspirate had been obtained since return from theatre and when reviewed by the surgeon, the tube was withdrawn five centimetres enabling aspiration of two hundred and fifty millilitres.

Day 4

Total Parenteral Nutrition (T.P.N.) intravenously via the central line was ordered to provide nutritional support to perform basic body metabolism since Jack was nil by mouth and would remain so until transfer to the ward. Oh (1991: 520) discusses the use of TPN to maintain health and offer resistance against illness.

Day 5

When reviewed by the medical staff in the morning it was decided Jack was well enough to be transferred to the ward. When examined, jack's abdomen was soft and bowel sounds were audible indicating a return of normal gastro-intestinal tract activity, hence the naso-gastric tube was removed.

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Nursing Objective 4: Promote rest/Comfort and relieve pain.

Rationale

Prompt attention to signs of anxiety and pain will encourage healing by decreasing the need to supply oxygen and nutrients to tissues.

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Expected Outcome

The patient identifies those symptoms that are indicators of his own anxiety.

The patient will remain pain free and comfortable.

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Nursing intervention

  1. Assess and document patient and family's level of anxiety.
  2. Explain all procedures before commencement.
  3. Explain and re-assure family about all procedures and practices involved with the patient.
  4. Involve pastoral care team if there is a spiritual need to be met.
  5. Ensure that the patient and his family are aware of social work services available.
  6. Adopt an open attitude regarding prognosis and the patients response to treatment.
  7. If questions are unable to be answered by nurse, involve medical staff for information to alleviate anxiety.
  8. Request communication with the doctor if family have expressed this need.
  9. Reassure patient during interactions by touch and empathetic verbal and non-verbal exchanges. Encourage patient to express any anger/irritation.
  10. Encourage a quiet environment be maintained by those around you.
  11. Reduce excessive stimulation by providing a quiet environment, especially at night. Limit contact with others if necessary. Document sleep pattern.
  12. Provide positive re-inforcement as patient increasingly contributes to activities of daily living.
  13. Position patient with pillows for comfort.
  14. Turn two hourly to relieve pressure areas.
  15. When the patient is conscious ask them to specify location and intensity of pain. Document the results.
  16. Encourage patient to support incision site when re-positioning or coughing.
  17. Administer morphine via continuous intravenous pump as ordered by doctor.
  18. Monitor and record hourly and continuously the rate and effect on the patient.
  19. Monitor when the patient has pain and what activities increase pain. Administer bolus dose of morphine prior to these activities.
  20. Be aware of side effects of pain relief such as respiratory depression, nausea and vomiting. Notify doctor if they exist.
  21. Administer anti-emetics if required as ordered by the doctor.
  22. Titrate amount of morphine to level of pain.
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Observed Outcomes

Day 1

A Continuous infusion of morphine was ordered and administered at three milligrams an hour via the central line. Jack's blood pressure returned to normal and he was comfortable.

Day 2 and 3

The morphine infusion continued at three milligrams an hour keeping Jack painfree but also awake and alert.

Day 4

It was suggested by the medical staff to wean the morphine infusion however, abdominal pain was experienced so the infusion was sustained at three millilitres an hour. It is important to keep the patient pain free enabling them to move, deep breathe and cough, and thereby improve lung expansion and prevent worsening of any existing respiratory problems.

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Nursing Objective 5: Promotion of wound healing and decreasing the potential for infection.

Rationale

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Expected Outcomes

Patient is free of signs and symptoms of infection as evidenced by:

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Nursing intervention

  1. Monitor and record patients core temperature hourly. Report greater than 38°C.
  2. Monitor white blood cell count as evidence of abnormalities.
  3. Blood cultures and sensitivities must be obtained if evidence of infection found.
  4. Change intravenous lines every 48 hours and change flask solutions every 24 hours.
  5. Inspect all insertion sites each shift for signs of infection (redness, swelling, hot haemoserous ooze). Sites for inspection include, arterial line, central venous catheter, indwelling catheter, intercostal catheters, peripheral cannulae and endo-tracheal tube.
  6. Ensure sterile technique for all occlusive dressings on the above sites including incisions.
  7. Employ aseptic technique when suctioning.
  8. Auscalate chest hourly record and report any adventitious sounds.
  9. Send routine third daily and prn swabs and sputum, and urine specimens for culture and sensitivity.
  10. Remove invasive lines as soon as possible.
  11. Administer intravenous antibiotics as ordered by doctor.
  12. Ensure two hourly mouthcare to keep mouth moist and decrease likelihood of infections such as thrush.
  13. Perform two hourly eye care to prevent infection and ulceration.
  14. Daily full sponge to maintain high level of general hygiene.
  15. Perform eight hourly indwelling catheter toilet.
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Observed Outcomes

Day 1

In the evening Jack became febrile with a temperature of 38.1°C. (normal 37.1°).

Blood cultures weren't taken at this stage, however, a prophylactic combination of antibiotics were ordered as follows:

  1. Ampicillin 1 gram every six hours intravenously. A broad spectrum antibiotic active against both gram positive and gram negative organisms. (Duncan et al., 1982: 96).
  2. Metronidazole five hundred milligrams twice a day. Treats protozoal infestation. (Duncan et al., 1982: 129)
  3. Centamicin one hundred milligrams twice a day. Bactericidal in action. (Duncan et al., 1982: 106)

Day 2

Antibiotics continued.

Day 3

Antibiotic therapy was ceased.

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Conclusion

After Jack had been transferred to the ward and when he was able, Jack was interviewed to assess the psychosocial implications of his illness and surgery.

The problems and concerns that may have faced both Jack and his family pre and post-operatively were discussed.

Jack perceived that he had an extensive and very supportive family. He stated he had no fears concerning the operation, as he felt that once it was completed he wouldn't be plagued with dysphagia and would gain more time to spend with his wife and family. Knowing his prognosis with adenocarcinoma, Jack hoped that surgery may enhance his survival.

Jack hoped that some of his wife's anxieties would be alleviated by the surgery. As his children were independent working adults, finances were not a problem.

In the ward setting Jack received education from the dietician on managing food intake with a reduced gastric capacity so as to avoid dumping syndrome. This is achieved by having six small meals a day and observing for any symptoms. Jack was happy with the education both he and his wife had received and felt that six meals a day would not greatly impinge on his lifestyle as he spent most of his days at home with his wife.

Jack was discharged home on day 16. He experienced no complications during the course of treatment and left hospital with an improved life expectancy.

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References

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