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Diagnoses, Procedures & Staff

VCTS Diagnoses, Procedures and Staff

J. Timothy Sherwood, MD, is a highly trained and experienced thoracic surgeon specializing in lung and esophageal cancer. He has developed one of the top thoracic programs in the country, performing over 500 cases in 2018. The Lung Cancer Surgery Program was ranked “high performing” by U.S. News & World Report in 2018.

Below please find the diagnoses that he treats and procedures that he performs.

We treat:

  • Achalasia
  • Barrett's Esophagus
  • Esophageal Cancer
  • Esophageal Perforation
  • Esophageal Stricture
  • Paraesophageal Hernia
  • Diaphragm Paralysis
  • Hyperhydrosis
  • Malignant Thymoma
  • Benign Thymoma
  • Brochial Stenosis
  • Malignant Pleural Effusion
  • Bronchopleural Fistula
  • Empyema
  • Sternal Lesion
  • Rib Lesion
  • Chest Wall Mass
  • Myasthenia Gravis
  • Pectus Excavatum
  • Lung Disease
  • COPD
  • Emphysema
  • Lung Nodule
  • Lung Cancer
  • Mesothelioma
  • Hodgkin's Lymphoma
  • Non-Hodgkin's Lymphoma
  • Med. Lymphadenopathy
  • Malignant Mediastinal Mass
  • Pneumothorax
  • Pleural Effusion

We perform:

  • Aspira Catheter Placement
  • Bronchoscopy w/ Cryoablation
  • Bronchoscopy
  • Bronchoscopy w/ Dilation & Stent
  • Chamberlain
  • Chest Tube Placement
  • Chest Tube Removal
  • Chest Wall Mass Excision/Resection
  • Diaphragm Plication
  • Decortication/Thoracotomy
  • Eloesser Flap
  • Esophagoscopy with Dilation
  • Esophagectomy Transhiatal/3-incision/Ivor Lewis
  • Esophagoscopy (Rigid/Flex)
  • Esophagoscopy for Biopsy
  • Esophagostomy Take Down
  • Gastric Pull Up
  • Incisional Hernia Repair
  • J-Tube Open
  • J-Tube Laparoscopic
  • Laparoscopic Nissen Fundoplication
  • Laparoscopic Para Esophageal Hernia Repair
  • Laparoscopic Heller Myotomy
  • Laparoscopy
  • VATS Lobectomy/Thoracotomy
  • Lung Mass Excision
  • Lung Wedge Resection (Thoracotomy)
  • Lung Volume Reduction
  • Lymphadenectomy
  • Mediastinal Mass Excision
  • VATS Mediastinal Mass Excision
  • Mediastinal Mass Robotic Excision
  • Mediastinoscopy
  • Mediastinotomy
  • Mediport Placement
  • Minimally Invasive Esophagectomy/MIE
  • Para-esophageal Hernia Repair/Belsey Procedure
  • Pericardial Window
  • Pleura Biopsy
  • Pleurx Catheter Placement
  • Pneumonectomy
  • Rib Resection
  • Sleeve Resection
  • Sternal Biopsy
  • Sternotomy
  • Thoracentesis
  • Thoracic Duct Ligation
  • Thoracic Sympathectomy
  • Thoracoplasty
  • Thoracotomy Lung Biopsy
  • Thoracotomy Decortication/Pleurodesis
  • Thymectomy
  • VATS Lung Biopsy
  • VATS Decortication
  • VATS Pleurodesis
  • VATS Wedge Resection
  • Mediport Placement
  • Neck Lymph Node Biopsy

Staff

  • Jenna Kollat, PA-C, MPAS
  • Emily Barnes, NP-C
  • Vicki Wallace, CRNP
  • Lisa Keel, CRNP
  • Emily Barnes, NP-C
  • Stephanie Strazinsky, PA-C
  • Mickey Raines, RN BSN
  • Kathleen Hebert, RN
  • Resina Walker – Coordinator, Thoracic Program

VATS/RATS Lung Resection

What is a VATS/RATS Lung Resection?

Definition: A lung resection is the removal of a part or entire lobe of your lung. There are different ways that a lung resection surgery can be performed, these will be discussed below.

There are three different approaches that your surgeon can use to remove part of your lung: VATS, RATS, and thoracotomy. VATS stands for video-assisted thoracoscopic surgery. RATS stands for robotic-assisted thoracoscopic surgery. A thoracotomy is a large incision made between the ribs, 4-6 inches in length, requiring rib spreading and disruption of the chest wall muscles. A VATS and RATS approach are both considered to be minimally invasive with small incision sites made. Your surgeon will discuss with you which of the above approaches is best for you. This operation is done under a general anesthesia and typically takes between 1 to 2 hours. After you are asleep, you will be positioned on your side with your arms perpendicular to your body. During a VATS or RATS approach, your surgeon will make small incisions on your chest that are about 2 to 4 cm in length. One of these incision sites is used for a camera to look around inside of your chest. The other incision sites are used for special instruments that are used to perform the operation. A special stapling device is used during the operation to remove lung tissue, divide blood vessels, and divide the bronchus (airway that is supplying your lung). Lymph node samples are typically removed during this procedure. VATS: Video-Assisted Thoracoscopic Surgery RATS: Robotic-Assisted Thoracoscopic Surgery Thoracotomy: Incision made between the ribs requiring rib spreading and disruption of the chest wall muscles

At the end of the operation, the incision sites that were made will be closed using absorbable stitches that are underneath the skin. Typically, one or two of those incision sites will be used for a chest tube which drains any air or fluid that may still be in the chest after the operation. You will typically wake up with 1 to 2 chest tubes in place following the operation. Any lung tissue and lymph node samples that were removed during the operation will be sent to the laboratory for analysis.

Your Operation: Surgical Approach

What are the Different Types of Lung Resections?

There are a few different types of lung resection procedures. Below we will discuss the differences between a wedge resection, lobectomy and segmentectomy.

Wedge Resection:

A wedge resection is a procedure that involves the surgical removal of a small, wedge-shaped piece of lung tissue. This can be used to remove or diagnose a small tumor or to diagnose different types of lung disease. This type of procedure is not ideal for treatment of lung cancer although it is sometimes preferred for patients who cannot tolerate the removal of a large section of lung when there may be a significant decrease in lung function. Your surgeon will discuss the reasons to undergo a wedge resection with you in detail prior to your procedure.

Anatomic Lung Resection: Lobectomy and Segmentectomy:

Lobectomy: A lobectomy is a surgical procedure where an entire lobe of your lung is removed for a variety of reasons, but most commonly for treatment of lung cancer. There are three lobes that make up your right lung (right upper lobe, right middle lobe, right lower lobe) and two lobes that make up your left lung (left upper lobe, left lower lobe). During this type of lung resection, blood supply to the specific lung lobe that is being removed does need to be closed off. The bronchus is a tube-like structure that supplies air to your lungs. This structure also needs to be closed off prior to the removal of the lung lobe. The above is done using a special type of stapler that will securely divide these structures.

Segmentectomy: A segmentectomy is a lung resection that involves the removal of part of one of the lobes of the lung. As stated above, the right lung is divided into three lobes and the left lung is divided into two lobes. These lobes are subdivided into segments. This type of resection spares more lung tissue as compared to a lobectomy, therefore leaving a patient with higher lung reserve. In certain circumstances, you may be a candidate for a segmental lung resection. Your surgeon will have this discussion with you and decide which type of lung resection is right for you.

Understanding your Operation

If you are having a section of your lung removed, there are different approaches that your surgeon can do to remove part of your lung. The approach depends on the location and extent of your disease as well as your overall health.

Changes to Planned Surgery

There is always a risk that your surgery may not be able to be completed as planned. Sometimes the surgeon may be unable to do your operation using the VATS/RATS approach and therefore must extend one of the incision sites to make a longer cut to enable the completion of the operation; this is called a thoracotomy. Very rarely, if there is bleeding during the operation that cannot be controlled through the VATS/RATS incisions, the surgeon will need to make a longer cut to gain direct vision and control the bleeding. In addition, sometimes unexpected findings may change the plan for the surgery.

Preparation for Surgery

Most importantly, if you currently smoke, we strongly recommend that you stop at least three weeks prior to your scheduled procedure. Your risk of post-operative complications is drastically increased if you continue to smoke up until the day of your surgery. You will be asked to start a daily walking program prior to your surgery. This will be discussed in detail with you by your surgeon. You will most likely be required to have some testing completed prior to your lung resection surgery. Some of these tests include a breathing test (pulmonary function test), EKG (heart tracing), cardiac stress test, echocardiogram and blood work. You will not be able to have anything to eat starting at midnight the night before your operation. You can have clear liquids, such as water or black coffee, up until 2 hours prior to your procedure. You will be given a pamphlet with more details regarding this. If you take medications routinely at home, we will discuss which of these you can take before your operation and which you cannot. Prior to your surgery after you have been put to sleep, a catheter will be inserted into your bladder to monitor your urine output during and after the surgery. 6

After your Surgery

After your surgery has been completed, you will be taken to the recovery room. The nursing staff will monitor your vital signs (blood pressure, breathing rate, oxygen levels, heart rate) and make sure that you are comfortable. You will wake up with 1 to 2 chest tubes in place. You will remain in recovery for about 2 hours after your procedure and then you will be taken to your hospital room in the step down unit (2 south). You will be given supplemental oxygen to help you breath. You will also be receiving fluids through your IV. You will be able to drink and eat as soon as you can tolerate. The urinary catheter is typically removed the morning after surgery. The chest tubes will remain in place for at least 24 to 48 hours depending on the amount of drainage and if there are any air leaks present; this is determined by your surgeon. You will be getting many chest x-rays while you are in the hospital, so expect to be awoken early in the morning for this to be completed. You will be instructed on breathing exercises and deep coughing to prevent any chest infections. You will also be encouraged to walk in the hallway and exercise your legs to prevent any blood clots from forming. Walking is very important and you will be encouraged to get out of bed the same day as your surgery.

Pain Control: Following your procedure you should expect to have pain. We will control your pain with a multi-modal regimen including Tylenol, Gabapentin (helps nerve pain), and Celebrex (anti-inflammatory). You will also be given a narcotic pain medication as needed. We try to keep IV pain medication to a minimum, but each patient is different and pain medications will be adjusted as needed.

General Care: You will be expected to start walking either the night of surgery or the day following. The dressings over your chest tube site will be removed following removal of the chest tubes. The other incision site dressings will be removed in the office at your follow-up appointment. Once your chest tubes are removed, you are able to shower daily and are encouraged to do so. Patients are typically ready to be discharged home 2-4 days after their procedure.

Risks and Possible Complications

With any surgical procedure, there are certain risks associated and these risks will depend on your health before undergoing the operation. Your surgeon will discuss these risks with you in detail.

Sore throat: It is normal to have a sore throat following surgery. It is a result of being under anesthesia and having a breathing tube during the operation. This should get better shortly after surgery.

Changes in blood pressure/heart rate: Sometimes your blood pressure may be lower/higher after having anesthesia. This is normally due to not having anything to eat or drink prior to surgery and the medications you receive in the operating room. Your blood pressure may normalize once you begin having fluid intake. Your heart rate may be disrupted as well during the procedure. You will be given a medication, Metoprolol, in the hospital and at discharge to prevent any irregular heart rhythms or rates.

Coughing up blood (Hemoptysis): It is normal to cough up small amounts of blood tinged sputum (usually the size of a quarter) for the first few days after lung resection surgery. This will gradually reduce with time.

Chest infection/Pneumonia: Breathing exercises, walking, getting out of bed and adequate pain control will reduce the risk of a chest infection. Your chance of chest infection or pneumonia is 8 times more likely if you are a current smoker. If you do develop a chest infection, you may need treatment with an antibiotic and your hospital stay may be longer.

Air leaks: This is when the cut surface of the lung tissue leaks air. This typically resolves on its own in a few days however it does mean that your chest tubes will have to stay in place while it heals. Sometimes this means you will be sent home with a chest tube in place.

Pneumothorax: Occasionally the lung will not fully inflate following surgery and this may require having a chest tube in place for a longer duration. Sometimes this can occur after the chest tube is removed. In these instances, another chest tube may have to be placed to allow the lung to fully re-expand.

Heart attack or stroke: This can occur during or after any surgery. The risk is higher in patients with a cardiac history or undiagnosed cardiac disease. For this reason, every patient will have cardiac work-up completed prior to your procedure.

Discharge

Your follow-up will be scheduled prior to you leaving the hospital. You will be seeing an advanced practice provider at your initial post-operative visit. You will be asked to get a chest x-ray completed at Medical Imaging of Fredericksburg prior to your appointment (that same day).

References:

1. VATS Instruments: Diagram showing video assisted thoracoscopy. Wikimedia.

2. RATS Set-up Picture: Robotic Approach to Lobectomy. Thoracic Key.

3. Wedge Resection Wedge Resection. Lung Cancer News Today.

4. Lobectomy Lobectomy. American Lung Cancer Association.

5. Wedge Resection/Lobectomy/Segmentectomy Lung Cancer. The Society of Thoracic Surgeons.

Pneumonectomy

What is a Pneumonectomy?

Definition: A pneumonectomy is a surgical procedure that involves the removal of the entire lung. See Figure 1. Lung cancer is the most common reason for this procedure. This procedure is typically done if the tumor is close to the center of the chest and therefore other types of lung resection, such as lobectomy, cannot be completed. It is important that all diseased tissue be removed from the body and sometimes this cannot be done unless the entire lung is removed. Pneumonectomy is the removal of the entire lung, right or left.

A pneumonectomy can only be completed through a thoracotomy incision. A thoracotomy is a surgical procedure in which a large cut is made between the ribs to see and reach the lung. This type of incision is made on either the right or left side of the chest, depending on which lung is to be removed. A thoracotomy requires rib spreading and a large 4- to 6-inch incision to gain access to view and treat the lungs. See Figure 2. A thoracotomy is performed for treatment of disease (typically lung cancer) and allows the surgeon to visualize, biopsy or remove tissue. During the operation, the affected lung will be collapsed, and the attached blood vessels and bronchus (airway that supplies the lung with oxygen) will be divided with a special stapling device. The diseased lung can then be removed through the incision.

Preparation for Surgery

Most importantly, if you currently smoke, we strongly recommend that you stop at least two weeks prior to your scheduled procedure. Your risk of post-operative complications is drastically increased if you continue to smoke up until the day of your surgery.

You will most likely be required to have some testing completed prior to your lung resection surgery. Some of these tests include a breathing test (pulmonary function test), EKG (heart tracing), cardiac stress test, echocardiogram, and blood work.

You will not be able to have anything to eat starting at midnight before your operation. You can have clear liquids, such as water or black coffee, up until 2 hours prior to your procedure. You will be given a pamphlet with more details regarding this. If you take medications routinely at home, we will discuss which of these you can take before your operation and which you cannot. Prior to your surgery, after you have been put to sleep, a catheter will be inserted into your bladder to monitor your urine output during and after the surgery.

You will also have an epidural catheter placed in your back prior to your surgery. This is done by the anesthesiologist and is typically completed in the bed that you will be in before you are taken back to the operating room. This catheter is used for pain control after your surgery. A thoracotomy incision is typically very painful but with this type of pain control, most patients receive adequate relief of pain. This catheter typically stays in place for 2-3 days and is then removed. After removal, you will be transitioned to pain medication by mouth.

After your Surgery

After your surgery has been completed, you will be taken to the intensive care unit (ICU). The nursing staff will monitor your vital signs (blood pressure, breathing rate, oxygen levels, heart rate) and make sure that you are comfortable. You will wake up with 1-2 chest tubes in place. Patients will remain in the ICU for the first night following surgery. Typically, patients undergoing pneumonectomy are transferred out of the ICU the day after surgery. You will then be brought to the step-down unit (2 South) for the rest of your hospital stay.

You will be given supplemental oxygen to help you breathe. You will also be receiving fluids through your IV. You will be able to drink and eat as soon as you can tolerate. The urinary catheter will typically remain in place until the removal of the epidural catheter. The chest tubes will remain in place for 24-48 hours. You will be getting many chest x-rays while you are in the hospital, so expect to be awoken early in the morning for this to be completed. You will be instructed on breathing exercises to prevent any chest infections. You will also be encouraged to walk in the hallway and exercise your legs to prevent any blood clots from forming. Walking is very important, and you will be encouraged to get out of bed the same day as your surgery.

Pain Control: Following your procedure you should expect to have pain, particularly with this type of incision. The rib spreading that is needed to gain access inside the chest is typically what causes the most discomfort in the post-operative period. You will have an epidural catheter placed in your back prior to your surgery to help with pain control after your surgery. We will also control your pain with a multi-modal regimen including Tylenol, Gabapentin (helps nerve pain), and Celebrex (anti-inflammatory). You will also be given a narcotic pain medication as needed. We try and keep IV pain medication to a minimum, but each patient is different, and we will adjust pain medications as needed.

General Care: You will be expected to start walking usually the night of surgery. The dressings over your chest tube sites will be removed following removal of the chest tubes. The other incision site dressings will be removed in the office at your follow-up appointment. Once your chest tubes are removed, you can shower daily and are encouraged to do so. The hospital stay for patients who undergo a pneumonectomy is typically 4 to 5 days.

Risks and Possible Complications

With any surgical procedure, there are certain risks. These risks will depend on your health before undergoing the operation. Your surgeon will discuss these risks with you in detail.

Sore throat: It is normal to have a sore throat following surgery. It is a result of being under anesthesia and from having a breathing tube during the operation. This should get better shortly after surgery.

Changes in blood pressure/heart rate: Sometimes your blood pressure may be lower/higher after having anesthesia. This is the result of not having anything to eat or drink prior to surgery and the medications you receive in the operating room. Your blood pressure may normalize once you begin having fluid intake. Your heart rate may be disrupted as well during the procedure. You will be given a medication, Metoprolol, in the hospital and at discharge to prevent any irregular heart rhythms or rates.

Coughing up blood (Hemoptysis): It is normal to cough up small amounts of blood tinged sputum (usually the size of a quarter) for the first few days after lung resection surgery. Any blood tinged sputum after pneumonectomy needs to be communicated to your surgeon.

Chest infection/Pneumonia: Breathing exercises, walking, getting out of bed and adequate pain control will reduce the risk of a chest infection. Your chance of chest infection is 80% higher if you are a current smoker. If you do develop a chest infection, you may need treatment with an antibiotic and your hospital stay may be longer.

Bronchopleural fistula: This is an opening between the bronchus (airway) that was divided during the surgery and the pleural space. This is a serious complication following a pneumonectomy and often requires another surgical procedure to close the fistula.

Heart attack or stroke: This can occur during or after any surgery, the risk is higher in patients with a cardiac history or undiagnosed cardiac disease. For this reason, every patient will have a cardiac work-up completed prior to your procedure.

Discharge

Your follow-up will be scheduled prior to you leaving the hospital, you will be seeing an advanced practice provider at your initial post-operative visit. You will be asked to get a chest x-ray completed at Medical Imaging of Fredericksburg prior to your appointment (that same day).

Heller Myotomy: Pre-Operative Education

Surgical Myotomy for Achalasia

Achalasia is a disorder of the esophagus that makes it difficult for foods and liquids to pass into the stomach. This process typically progresses over time with increasing esophageal enlargement despite therapy. A Heller Myotomy is a procedure in which the lower esophageal muscles are cut to help open the abnormally tight valve between the esophagus and the stomach. This helps to relieve dysphagia (difficulty swallowing).

Procedure Overview

Heller Myotomy is performed under general anesthesia, so you will be asleep throughout the entire procedure. It is performed through 5 to 6 small incisions in your abdomen. (Figure 1) The surgery can take approximately 2 to 4 hours.

In-Hospital Recovery

Pain Management: A multi-modal pain regimen is used along with narcotic pain medications. You will receive three medications prior to surgery, while in the hospital and upon discharge home to help control your pain postoperatively. These are: Tylenol, Gabapentin, and Celebrex or ibuprofen. Depending on your age, you will also be given an anti-nausea patch called Scopolamine.

A stronger pain medication may be given, to include a narcotic, for any breakthrough pain.

Diet: You will be allowed a clear liquid diet within the first 24 hours of your surgery. Sips of water to take medication will be allowed. On the day following your procedure, you will have a special test performed (barium esophagram) in which you will be asked to swallow contrast and x-rays will be taken. If this study is acceptable and no leak is shown, you will be advanced to a liquid diet. You will most likely be discharged at this point and given specific instructions on what diet to follow upon returning home.

Recovery at Home

Pain: As stated above, you will be given prescriptions and specific instructions for a pain control regimen. These medications include Tylenol, Gabapentin, Celebrex or ibruprofen, and possibly a stronger pain medication for breakthrough pain.

Activity: After discharge, your activity level should increase gradually over time. You should avoid heavy lifting for an INDEFINITE amount of time following surgery, and this will be reviewed with you after surgery. Avoid lifting anything heavier than 20-25 lbs. Most patients can return to work in 1 to 2 weeks depending on their occupation.

Driving: You should avoid driving for at least 5 days following surgery. You are not cleared to drive until you are no longer taking narcotic pain medication.

Wound Care: Your incision sites will be covered with purple-colored surgical glue called Dermabond. This glue will come off on its own with time. You may shower normally after surgery, pat-do not rub-your incision sites and leave them open to air. Do not soak in a bathtub or swim in a pool for at least 4-6 weeks following your surgery.

Pre-Operative Testing

A series of tests may be performed to determine if you are a candidate for esophageal surgery. These include upper endoscopy, barium swallow test, ambulatory pH test, and esophageal manometry.

New Anatomy

During your procedure, the muscles that cover the lower esophagus and valve that connects the esophagus to the stomach are cut to help open this area. This is called a myotomy. (Figure 2) Some patients experience worsening reflux following this procedure and therefore a partial anterior fundoplication (Dor fundoplication) will be performed to decrease the likelihood of this occurring. A partial fundoplication is when the top part of the stomach, or the fundus, is wrapped over top of the end of the esophagus and tied down with special suture. (Figure 3)

Surgical Results

Most patients have good outcomes with surgical myotomy, with better outcomes compared to non-surgical treatment, although 10%-30% of patients will experience recurrence within 10 years of surgery. Recent studies show that almost all patients will have to undergo some other type of intervention during their lifetime.

Minimally Invasive Esophagectomy

What is an Esophagectomy?

Definition: An esophagectomy is a surgical procedure that removes part of the diseased esophagus (tube between your mouth and stomach) and reconstructs it using part of another organ, typically the stomach. This type of procedure is typically used for esophageal cancer. While this procedure may be completed in many ways, a minimally invasive approach is always the first consideration. Esophagectomy: a surgical procedure to remove part of the esophagus and then reconstruct it typically using the Esophagectomy is the cornerstone of multidisciplinary therapy for patients with localized disease, or disease confined to the esophagus. About 22% of patients diagnosed with esophageal cancer have localized disease.

Prior to surgery, some patients will require chemotherapy, radiation therapy, or a combination of both. Treatment given prior to surgery is called neoadjuvant therapy. The decision to give neoadjuvant therapy is based on the clinical stage of your cancer. Your surgeon and oncologist will discuss this with you during your consultation.

Figure 1 below demonstrates the different regions and anatomy of the esophagus. Your tumor may be in the cervical region, upper thoracic esophagus, middle thoracic esophagus, or lower thoracic esophagus.

AJCC 8th Edition Regions of the Esophagus

Figure 1 Modified Image from Rice, TW, Kelsen D, Blackstone EH, et al. Esophagus and esophagogastric junction. In: AJCC Cancer Staging Manual, 8th Ed, Amin MB (ed), Springer Science+Business Media, LLC, New York, 2017.

Surgical Approach:

Within this section, the different approaches to an esophagectomy are discussed. Please keep in mind that each surgical approach depends on the patient. Your surgeon will discuss this with you in detail prior to your scheduled procedure.

Three-Incision Esophagectomy:

The three-incision esophagectomy refers to the three access points that the surgeon will use to complete the procedure. The first area is the right chest. When possible, this is done in a minimally invasive approach known as a Video-Assisted Thoracoscopic Surgery (VATS). During this approach, small incisions, 2 to 4 cm in length, are made on your right chest. A camera is used to help the surgeon see your internal anatomy. The other incision sites are used to insert special instruments that are needed to complete your surgery (Figure 2).

The abdomen is the next part of your body that will need to be accessed. This is always attempted using a minimally invasive approach, with 5 to 6 small incisions (Figure 3). Again, a camera is placed through one of these sites and used to look directly at your internal organs. Following the laparoscopic portion of the operation, an open incision from the sternum to the navel will be made so that your surgeon can access your stomach in preparation for the creation of the gastric conduit (the portion of your stomach that will replace the diseased portion of your esophagus) (Figure 4).

The last incision is made on the left side of the neck. This incision allows your surgeon to attach the healthy esophagus and new gastric conduit (the portion of the stomach that replaces the diseased portion of your esophagus). Your surgeon will use a variety of stitches and stapling devices to make sure this connection is tight and secure (Figure 5).

Preparation for Surgery

You will be required to have a series of tests prior to your scheduled procedure. These tests include a breathing test (pulmonary function testing), a cardiac stress test, echocardiogram, EKG (heart tracing), and blood work.

You will not be able to eat starting at midnight the night before your operation. You may have clear liquids, such as water or black coffee, up until 2 hours prior to your procedure. You will be given a pamphlet with more details about this. If you take medications routinely at home, we will discuss which of these you can take before your operation.

After you have been placed under general anesthesia, a catheter is inserted into your bladder to monitor your urine output during and after surgery. You will also have an epidural catheter placed in your back prior to your surgery. This is done by the anesthesiologist and is typically completed before you are taken to the operating room. This catheter is used for pain control after your surgery and typically stays in place for 3 to 4 days before being removed. After the removal, you will be transitioned to oral pain medication.

After your Surgery

Your operation will typically take anywhere from 8 to 12 hours. After your surgery has been completed, you will recover in the intensive care unit (ICU) where the nursing staff will monitor you closely around the clock. Most patients are brought into the ICU from the operating room with a breathing tube still in place. This breathing tube is typically removed the night of surgery or the following morning. You should expect to have a tube down your nose that goes into your stomach, 1 to 2 chest tubes on the right side of your chest, a small drain from the incision on the left side of your neck, a urinary catheter, and a feeding tube. You will remain in the ICU for up to 3 days following your surgery, depending on your recovery process. Once you are stable and ready to be transferred out of the ICU, you will be taken to the step-down unit, 2 South. Patients are typically stable enough to go home within 6 or 7 days following surgery. You will go home with your feeding tube in place; all other lines and tubes will be removed before you leave the hospital.

Diet: You will not be able to take anything by mouth for the first 4 to 5 days following your surgery. Nutrition will be given through your feeding tube during this time to help you stay strong during recovery. You will undergo a study called a barium esophagram about 5 days after your surgery. During this study, you will swallow contrast and x-rays will be taken. This test looks to see if the connection between the healthy esophagus and new gastric conduit (the portion of the stomach that replaces the diseased portion of your esophagus) is completely closed. If the study shows no leak, you will be able to start a clear liquid diet. Your diet will gradually progress to include all liquids. Upon discharge, we will review the diet you are to follow. Your diet upon discharge is dependent on your progress while in the hospital and will be decided by your surgeon. You may also be required to continue tube feedings at home.

References:

1. Figure 1: AJCC: American Joint Committee on Cancer; v: vein. Modified from: Rice, TW, Kelsen D, Blackstone EH, et al. Esophagus and esophagogastric junction. In: AJCC Cancer Staging Manual, 8th Ed, Amin MB (ed), Springer Science+Business Media, LLC, New York, 2017. Graphic 111260 Version 5.0

2. Figures 5 and 6: http://www.cancer.ca/en/cancer-information/cancer-type/esophageal/ treatment/surgery/?region=on

3. General information throughout document: https://www.uptodate.com/contents/clinical-manifestationsdiagnosis- and-staging-of-esophageal-cancer?search=esophageal%20 cancer&source=search_result&selectedTitle=1~150&usage_ type=default&display_rank=1

Anti-Reflux Surgery

Your Guide to Anti-Reflux Surgery

A laparoscopic paraesophageal hernia repair is a minimally invasive procedure that reconstructs the malfunctioning valve where the esophagus goes into the stomach. This procedure also repairs the defect in your diaphragm that may be causing your stomach or other abdominal organs to protrude into your chest. When surgery is successful, reflux is stopped and acid suppressing medications should no longer be needed.

Procedure Overview

Laparoscopic paraesophageal hernia repair is performed under general anesthesia, meaning you will be asleep throughout the entire surgery. Six small incisions are made on your abdomen to provide your surgeon with access to the affected organs (Figure 1). Surgery typically takes between 1 and 3 hours.

In-Hospital Recovery

Pain Management: A multi-modal pain regimen is used in lieu of narcotic pain medications. You will receive three medications prior to surgery, while in the hospital and upon discharge home to help control your pain post-operatively. These are: Tylenol, Gabapentin, and Celebrex. If you are under age 65, you will also be given an anti-nausea patch called Scopolamine. A stronger pain medication may be given for any breakthrough pain you may have.

Diet: You will be kept on a clear liquid diet the day of surgery. On the morning after your surgery, you will be allowed a full liquid diet. Upon discharge, you will be given specific instructions on what diet to follow at home. At your follow-up appointment we will discuss next steps in your diet.

Recovery at Home

Pain: As stated above, you will be given prescriptions and specific instructions for a pain control regimen. These medications include Tylenol, Gabapentin, Celebrex, and possibly a stronger pain medication for breakthrough pain.

Activity: After discharge, your activity level should increase gradually over time. You are to avoid heavy lifting for an INDEFINITE amount of time following surgery. No lifting anything heavier than 15 lbs. Most patients can return to work in 1 to 2 weeks depending on occupation.

Driving: You are not to drive for 5 days following surgery. You are not cleared to drive until you are no longer taking narcotic pain medication.

Wound Care: Your incision sites will be covered with purple-colored surgical glue called Dermabond. This glue will come off on its own with time. You may shower normally after surgery, pat-do not rub-your incision sites and leave them open to air. Do not soak in a bathtub or swim in a pool for at least 6 weeks following your surgery.

Pre-Operative Testing

A series of tests may be performed to determine if you are a candidate for anti-reflux surgery. These include upper endoscopy, ambulatory pH testing, and manometry.

New Anatomy

Following your anti-reflux surgery, your stomach will be in a new position in the abdomen. This is because the part of your stomach called the fundus is now acting as the valve that separates the esophagus from your stomach. The fundus (or top part of the stomach) will now be wrapped, either 360 degrees or 270 degrees, around the esophagus. This new valve is what will eliminate reflux (Figures 2 and 3).

Long-Term Side Effects

Most commonly noted long-term side effects include bloating, diarrhea, and very mild dysphagia (difficulty swallowing). Also, the return of symptoms (failure of the procedure) is possible. There is some variability, but the likelihood of developing dysphagia is less than 5%. Diarrhea and bloating develop in 10% of patients. Surgical Results Results do vary depending on your exact symptoms and other factors. Although, when asked 5 to 10 years following surgery, 80-90% of patients have stated that they are satisfied with results and would undergo it again.

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