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Oesophageal & Cardia tumours

¬ Dysphagia for solids, liquids, saliva ¬ Past history of oesophago-gastric disorders or surgery ¬ Anticoagulant use, venous thrombo-embolism ¬ Endoscopy & biopsy - dilatation at this stage should be avoided ¬ Staging laparoscopy (for lower 1/3 tumours) Domestic, social factors ϖ Social worker and dietician involvement appropriate ϖ Relatives counselled re treatment options, prognosis, and rehabilitation ϖ Home supports or rehabilitation institution considered Decision-making ϖ Before any treatment all patients must be referred for multi-disciplinary assessment by ¬ Upper GI Research Nurse (Allison Forde) ϖ If patients cannot swallow fluids, a PICC line & TPN should be commenced immediately ¬ A PEG must not be inserted unless a decision has been made to rule out surgery ¬ Naso-enteric feeding is a possible option but may be difficult to place, and persistent efforts ¬ Definitive chemoradiotherapy - at this stage a PEG may be inserted to replace TPN until ¬ Surgery & preoperative chemoradiotherapy ϖ Patients are candidates for palliation if the disease is inoperable by virtue of being locally invasive (T4 - aorta/airway) or metastatic, or if age or co-morbidity preclude attempted cure by surgery or definitive chemoradiotherapy. Nodal disease alone does not confer inoperability. ¬ Palliative chemotherapy/chemoradiotherapy - at this stage a PEG may be inserted to replace ¬ Self-expanding metallic stents - should be used as 2nd line palliation if chemoradiotherapy unsuitable or failed. Stents should be placed endoscopically in conjunction with a dilatation ¬ Argon Beam Coagulation - an alternative as 2nd line palliation to stents if chemoradiotherapy ϖ Occasionally patients will require/request no treatment; most because of significant co-morbidity ¬ Palliative care consultation is then appropriate Surgical Management ϖ Preop education about chest physio, DB & C exercises ϖ The decision to perform an Ivor-Lewis (2-stage oesophagectomy) in preference to a thoracoscopically-assisted 3 stage oesophagectomy is determined by significant encroachment of the tumour into the stomach beyond the oesophago-gastric junction ϖ All oesophagectomies require an CCMU or 5F booking Post-operative Care ϖ IVT - do not overfill as patients are at risk of ARDS ϖ Antiemetics - tropisetron 2mg IV BD prn ϖ Antibiotics - intra-operative ceftriaxone 1g IV ϖ Thromboembolism prophylaxis - heparin 5000 units SC BD postop (check with anaesthetist timing ϖ Feeding jejunostomy - flush with normal saline 20mls TDS. Commence jejunostomy feeds day 2. ϖ UWSD - remove on Consultant's advice. ϖ Abdominal drains - remove on Consultant's advice ϖ NGT - to remain in-situ until gastrografin swallow day 5 ϖ Chest physio - BD whilst in CCMU/5F. Triflow ϖ Ski ropes on beds to allow patients to sit up for an effective cough. ϖ Regular 4/24 nebulised saline and ventolin. ϖ Oral intake - graduated fluids & food after gastrografin swallow day 5. Reduce jejunostomy feeds Analysis Documentation of "near misses"


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