Benign Tumors and Cancer of the Esophagus

BENIGN TUMORS OF THE ESOPHAGUS

Benign tumors can arise anywhere along the esophagus. The most common lesion is a leiomyoma (tumor of the smooth muscle), which can occlude the lumen of the esophagus. Most benign tu-mors are asymptomatic and are distinguished from cancerous le-sions by a biopsy. Small lesions are excised during esophagoscopy; lesions that occur within the wall of the esophagus may require treatment via a thoracotomy.

CANCER OF THE ESOPHAGUS

In the United States, carcinoma of the esophagus occurs more than three times as often in men as in women. It is seen more fre-quently in African Americans than in Caucasians and usually oc-curs in the fifth decade of life. Cancer of the esophagus has a much higher incidence in other parts of the world, including China and northern Iran (Greenlee, 2001; Castell & Richter, 1999).

Chronic irritation is a risk factor for esophageal cancer. In the United States, cancer of the esophagus has been associated with ingestion of alcohol and with the use of tobacco. There seems to be an association between GERD and adenocarcinoma of the esophagus. People with Barrett’s esophagus (which is caused by chronic irritation of mucous membranes due to reflux of gastric and duodenal contents) have a higher incidence of esophageal cancer (Stein, 1999).

Pathophysiology

Esophageal cancer is usually of the squamous cell epidermoid type; however, the incidence of adenocarcinoma of the esopha-gus is increasing in the United States. Tumor cells may spread be-neath the esophageal mucosa or directly into, through, and beyond the muscle layers into the lymphatics. In the latter stages,obstruction of the esophagus is noted, with possible perforation into the mediastinum and erosion into the great vessels.

Clinical Manifestations

Many patients have an advanced ulcerated lesion of the esopha-gus before symptoms are manifested. Symptoms include dyspha-gia, initially with solid foods and eventually with liquids; a sensation of a mass in the throat; painful swallowing; substernal pain or fullness; and, later, regurgitation of undigested food with foul breath and hiccups. The patient first becomes aware of in-termittent and increasing difficulty in swallowing. As the tumor progresses and the obstruction becomes more complete, even liq-uids cannot pass into the stomach. Regurgitation of food and saliva occurs, hemorrhage may take place, and progressive loss of weight and strength occurs from starvation. Later symptoms in-clude substernal pain, persistent hiccup, respiratory difficulty, and foul breath. The delay between the onset of early symptoms and the time when the patient seeks medical advice is often 12 to 18 months. Anyone with swallowing difficulties should be en-couraged to consult a physician immediately.

Assessment and Diagnostic Findings

Although new endoscopic techniques are being studied for screening and diagnosis of esophageal cancer, currently diagno-sis is confirmed most often by EGD with biopsy and brushings. Bronchoscopy usually is performed, especially in tumors of the middle and the upper third of the esophagus, to determine whether the trachea has been affected and to help determine whether the le-sion can be removed. Endoscopic ultrasound or mediastinoscopy is used to determine whether the cancer has spread to the nodes and other mediastinal structures. Cancer of the lower end of the esophagus may be caused by adenocarcinoma of the stomach that extends upward into the esophagus.

Medical Management

If esophageal cancer is found at an early stage, treatment goals may be directed toward cure; however, it is often found in late stages, making relief of symptoms the only reasonable goal of therapy. Treatment may include surgery, radiation, chemotherapy, or a com-bination of these modalities, depending on the extent of the disease.

Standard surgical management includes a total resection of the esophagus (esophagectomy) with removal of the tumor plus a wide tumor-free margin of the esophagus and the lymph nodes in the area. The surgical approach may be through the thorax or the abdomen, depending on the location of the tumor. When tu-mors occur in the cervical or upper thoracic area, esophageal con-tinuity may be maintained by free jejunal graft transfer, in which the tumor is removed and the area is replaced with a portion of the jejunum (Fig. 35-9). A segment of the colon may be used, or the stomach can be elevated into the chest and the proximal section of the esophagus anastomosed to the stomach.

Tumors of the lower thoracic esophagus are more amenable to surgery than are tumors located higher in the esophagus, and gastrointestinal tract integrity is maintained by anastomosing the lower esophagus to the stomach.

Surgical resection of the esophagus has a relatively high mor-tality rate because of infection, pulmonary complications, or leak-age through the anastomosis. Postoperatively, the patient will have a nasogastric tube in place that should not be manipulated. The patient is given nothing by mouth until x-ray studies confirm that the anastomosis is secure and not leaking. Preoperative radiation therapy or chemotherapy, or both, may be used; however, treatment is based on type of cell, tumor spread, and patient condition.

Palliative treatment may be necessary to keep the esophagus open, to assist with nutrition, and to control saliva. Palliation may be accomplished with dilation of the esophagus, laser therapy, placement of an endoprosthesis (stent), radiation, or chemother-apy. Because the ideal method of treating esophageal cancer has not yet been found, treatment is individually determined.

Nursing Management

Intervention is directed toward improving the patient’s nutri-tional and physical condition in preparation for surgery, radia-tion therapy, or chemotherapy. A program to promote weight gain based on a high-calorie and high-protein diet, in liquid or soft form, is provided if adequate food can be taken by mouth. If this is not possible, parenteral or enteral nutrition is initiated. Nutritional status is monitored throughout treatment. The pa-tient is informed about the nature of the postoperative equipment that will be used, including that required for closed chest drainage, nasogastric suction, parenteral fluid therapy, and gas-tric intubation. Immediate postoperative care is similar to that pro-vided for patients undergoing thoracic surgery. After recovering from the effects of anesthesia, the patient is placed in a low Fowler’s position, and later in a Fowler’s position, to assist in preventing re-flux of gastric secretions. The patient is observed carefully for re-gurgitation and dyspnea. A common postoperative complication is aspiration pneumonia. The patient’s temperature is monitored to detect any elevation that may indicate aspiration or seepage of fluid through the operative site into the mediastinum.

If jejunal grafting has been performed, the nurse checks for graft viability hourly for at least the first 12 hours. To make the graft visible, the surgeon usually brings a portion of the jejunum to the exterior neck by way of a small incision. Moist gauze cov-ers the external portion of the graft. The gauze is removed briefly to assess the graft for color and to assess for the presence of a pulse by means of Doppler ultrasonography.If an endoprosthesis has been placed or an anastomosis has been performed, a functioning continuum will exist between the throat and the stomach. Immediately after surgery, the nasogas-tric tube should be marked for position, and the physician is no-tified if displacement occurs. The nurse does not attempt to reinsert a displaced nasogastric tube, because damage to the anas-tomosis may occur. The nasogastric tube is removed 5 to 7 days after surgery, and a barium swallow is performed to assess for any anastomotic leak before the patient is allowed to eat.

Once feeding begins, the nurse encourages the patient to swal-low small sips of water and, later, small amounts of pureed food. When the patient is able to increase food intake to an adequate amount, parenteral fluids are discontinued. If an endoprosthesis is used, it may easily become obstructed if food is not chewed suf-ficiently. After each meal, the patient remains upright for at least 2 hours to allow the food to move through the gastrointestinal tract. It is a challenge to encourage the patient to eat, because ap-petite is usually poor. Family involvement and home-cooked fa-vorite foods may help the patient to eat. Antacids may help those with gastric distress.

If radiation is part of the therapy, the patient’s appetite is fur-ther depressed and esophagitis may occur, causing pain when food is eaten. Liquid supplements may be more easily tolerated.

Often, in either the preoperative or the postoperative period, an obstructed or nearly obstructed esophagus causes difficulty with ex-cess saliva, so that drooling becomes a problem. Oral suction may be used if the patient is unable to handle oral secretions, or a wick-type gauze may be placed at the corner of the mouth to direct se-cretions to a dressing or emesis basin. The possibility that the patient may aspirate saliva into the tracheobronchial tree and de-velop pneumonia is of great concern.

When the patient is ready to go home, the family is instructed about how to promote nutrition, what observations to make, what measures to take if complications occur, how to keep the pa-tient comfortable, and how to obtain needed physical and emo-tional support.