Thy Kingdom come, Thy will be done in Earth as it is in Heaven

Malignant lesions of the esophagus occur in four types worldwide: squamous cell, adenocarcinoma, carcinosarcoma, and sarcoma.

Pathophysiology and Etiology

Incidence

Incidence of adenocarcinoma of the distal and middle third of the esophagus appears to be increasing in the Western world.
Squamous cell carcinoma, most often originating in the upper half of the esophagus, appears to have an incidence equal to adenocarcinoma.
Highest rate in the United States occurs in men, who are usually older than age 60; more common in nonwhite males.

Associated Factors

Cause is unknown but has been associated with:

Barrett's esophagus.
Achalasia.
Chronic use of alcohol and tobacco (squamous cell carcinoma).
Genetic predispositionâ€”nonwhite male population.

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Ingestion of caustic substances (such as lye), which cause esophageal strictures.
Other head and neck cancers.

Clinical Manifestations

Dysphagia is the usual presenting symptom, although it is a late sign, by which time there often is regional or systemic involvement.
Mild, atypical chest pain associated with eating precedes dysphagia but is rarely significant enough for the patient to seek health care.
Pain on swallowing (odynophagia).
Progressive weight loss.
Hoarseness (if laryngeal involvement).
Lymphadenopathy (supraclavicular or cervical) or hepatomegaly with metastatic involvement.
Later symptomsâ€”hiccups, respiratory difficulty, foul breath, regurgitation of food and saliva.

Diagnostic Evaluation

Chest X-ray may show adenopathy; mediastinal, widening, metastasis; or a tracheoesophageal fistula.
Endoscopy with cytology and biopsy.
Surveillance endoscopy of Barrett's esophagus is beneficial for early detection of malignant changes.
Barium esophagram may show polypoid, infiltrative, or ulcerative lesion requiring biopsy.
CT scanning may be helpful in delineating the extent of the tumor as well as in identifying presence of adjacent tissue invasion and metastases.

Management

The goal of treatment may be cure or palliation, depending on the staging of the tumor and the patient's overall condition in relation to nutritional, cardiovascular, pulmonary, and functional status.
The wide variability in treatment reflects the overall poor results from any one approach.
Surgery.
- Lesions of the middle and lower esophagus are excised with use of the thoracotomy approach with esophagogastrectomy or colon interposition (section of colon is used to replace the excised portion of the esophagus).
- Lesions of the cervical esophagus are excised with a bilateral neck dissection and esophagogastrectomy; laryngectomy and thyroidectomy may be necessary.
- A two-step approach may be selected when resection with a cervical esophagostomy and feeding gastrostomy are performed initially; subsequent reconstructive surgery is performed.
Radiation, chemotherapy, or their combination; combination therapy appears to have better results.
Palliative treatment of dysphagia through dilation done by endoscopy or laser therapy.
The goal of palliative treatment is to reduce the complications of the tumor to improve quality of life. Any one or a combination of the aforementioned therapies can be used for palliative treatment.

Complications

Preoperatively: malnutrition, aspiration pneumonitis; hemorrhage; sepsis; tracheoesophageal fistula
Postoperatively: pneumonia, dumping syndrome, nutritional deficiencies, reflux esophagitis, anastomosis leakage

Nursing Assessment

Nursing Diagnoses

Imbalanced Nutrition: Less Than Body Requirements, related to disease process and treatment
Risk for Infection related to chronic disease, invasive procedures and treatment
Ineffective Coping related to dealing with cancer

Nursing Interventions

Improving Nutritional and Fluid Status

Provide the preoperative patient with a high-protein, high-calorie diet as tolerated. Nutritional supplements may be indicated. TPN may be ordered if unable to take food or fluids orally.
Postoperatively, administer I.V. fluids as prescribed. Initially, the patient may require large volumes if extensive excision of lymph nodes was performed. TPN may be ordered.
Assess for bowel sounds; administer fluids per NG tube and liquid feedings through jejunostomy, as prescribed.
Encourage patient in advancing diet from liquids to soft foods.
Remind patient to remain in upright position for approximately 2 hours after eating to promote digestion.
Provide mouth care for patient comfort and hygiene.

Monitoring for Complications

Monitor blood pressure (BP), pulse, respiration, and temperature to note early onset of hemorrhage, infection, dysrhythmias, aspiration, or anastomosis leakage.
Observe drainage from incision and/or chest tube for bleeding or purulence.
Monitor arterial blood gas (ABG) levels, manage pain, suction, provide chest physiotherapy, and provide oxygen as indicated.

Strengthening Individual Coping

Encourage patient to utilize support system during treatment and recovery process.
Provide information about laryngectomy, gastrostomy, and other procedures related to surgery, as indicated.

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Provide training in relaxation techniques and diversional therapy for anxiety and pain control after surgery.
Refer to the American Cancer Society, http://www.acs.org, for additional information and sources of support.

Patient Education and Health Maintenance

Encourage the patient to avoid overeating, take small bites, chew food well; avoid chunks of meat and stringy raw vegetables and fruit.
Depending on type of surgery, frequent small meals may be better tolerated.
Encourage rest postoperatively and advancing activities as tolerated.
Instruct patient regarding signs and symptoms of complications to report: nausea, vomiting, elevated temperature, cough, difficulty swallowing.

Evaluation: Expected Outcomes

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