1. THE FIVE TUBE CHALLENGE CARE OF THE ESOPHAGECTOMY PATIENT

2. 5 TUBES Epidural Foley Catheter NG tube J-tube Chest tube

3. ESOPHAGECTOMY An esophagectomy is performed to treat the following conditions: Advanced cases of Barrett's esophagus, a pre- cancerous condition. Since most patients with Barrett's do not develop esophageal cancer and the operation carries significant risk of complication, esophagectomy is only considered for cases of high-grade dysplasia, a late stage of the condition. Esophageal cancer that has not spread (metastasized) to other organs in good surgical candidates, healthy enough for the surgery, which is complex and lengthy

4. APPROACHES The two most commonly performed surgeries for are the transhiatal esophagectomy (THE) and the transthoracic esophagectomy (TTE), also known as the Ivor-Lewis Procedure. In both procedures, the patient's diseased esophagus and proximal (top part) stomach is removed. A segment of the stomach is then pulled up into the chest and connected to the remaining normal esophagus, forming a new esophagus. Third, minimally invasive esophagectomies. This procedure uses tiny incisions and a small scope, through which miniature surgical instruments are passed, connected to a video camera. The camera sends a magnified image from inside the body to a monitor, giving the surgeon a close-up view of the anatomy. The advantages of minimally invasive esophagectomy include: Less post-operative pain Faster recovery from surgery Shorter hospital stay A more rapid return to work and normal activities

5. APPROACHES Transhiatal esophagectomy involves both an abdominal incision and a cervical (neck) incisionThe cervical component of the operation involves opening the neck and retracting the sternocleidomastoid muscle laterally. Transthoracic esophagectomy involves an abdominal incision and a thoracotomy. The mid and lower parts of the esophagus are removed along with the upper part of the stomach. The abdominal component of the procedure involves complete mobilization of the stomach.. This procedure uses tiny incisions and a small scope, through which miniature surgical instruments are passed, connected to a video camera. The camera sends a magnified image from inside the body to a monitor, giving the surgeon a close-up view of the anatomy.

6. PAIN MANGEMENT Management of pain is key in these patients, and adequate pain control reduces the mortality and morbidity of patients after esophagectomy. 27 In 1996, Tsui et al 27 found that adequate pain control contributed to decreased cardiopulmonary complications, shorter hospital stay, and decreased mortality in patients undergoing transthoracic esophagectomy. Initial pain management may consist of morphine or bupivacaine given epidurally, patient-controlled analgesia with morphine, or a combination of both, at the physician’s discretion. Pain should be reassessed as often as necessary to ensure that it is under control. Because these patients receive nothing by mouth for 5 to 7 days, intravenous or epidural pain medications are used. 27

7. NURSING CARE OF EPIDURAL Inspection of Dressing for erythema, edema, and leakage. Adequate Pain management: -frequent evaluation of patient pain level on 0-10 scale, Notify Anesthesia if need for change in Dose Most importantly evaluate for over sedation if concerned turn off epidural and notify Physician

8. CHEST TUBE MANAGEMENT Chest tubes will remain in until after day 6 or 7 Regular monitoring of chest tube drainage amount and color on 6a-2pand 10p schedule always making chest tube collection cylinder with sharpie with date, and time Change chest tube dressing once every 24 hours Notify Provider of any questions you may have regarding chest tube or drainage.

9. FOLEY CATHETER Foley catheter will stay in place for 6-7 days due to epidural placement Specific orders will be given in regards to removal of catheter Strict Intake and Output is vitally important to these patient because of inability to have PO intake

10. J-TUBE A jejunostomy feeding tube is often placed during surgery and is left clamped until used Jejunostomy site care should be performed on a daily basis. Wash the surrounding skin with a gentle soap, and assess the skin for any signs of irritation or breakdown Tube feedings will be started on day 2 or 3 depending on Surgeon, however NEVER start tube feedings until after OK from Surgeon is received.

11. LOPEZ VALVE Lopez® Valve enables easy sampling. ■ maintains closed-system integrity, including during patient transport ■ allows for easy administration of fluids and medications, and tube feedings ■ prevents accidental healthcare worker exposure to potentially infectious bodily fluids

12. NG-TUBE All patients have a nasogastric tube after esophagectomy. Do not move, manipulate, or irrigate the nasogastric tube. If the tube comes out for any reason, do not attempt to replace it. The nasogastric tube goes through the anastomosis and is usually bridled in place. Attempting to replace the nasogastric tube may result in damage to the anastomosis. Be sure to notify a physician immediately if the tube becomes dislodged or does not appear to be functioning properly. Monitor the tube for patency and assess the drainage for color and amount.

13. NG TUBE NG tubes must be functional and connected to LWS. This suction must be checked frequently for function. If the NG does not work properly we run the risk of patient developing nausea and vomiting and tearing the esophagus anastomosis. Or worse possible scenario there is an esophageal leak and gastric contents back up into the lungs.

14. NG TUBE Problem: Build-up of reflux due to NG tube clogging increases the risk of gastric fluid aspiration.

15. BARD AIR VENT Solution This patented 2-way filter allows stomach decompression. Gases can escape and ambient air can enter for proper sumping.

16. PROPER AIR VENT USAGE Luer-lock connector interface enables easyclearing of clogs without removing the filter—just inject 15cc of air and maintain a closed system.

17. NG TUBE Never cap the NG tube with plug from Keith valve unless discussed with Surgeon.