An esophagectomy, the surgical removal of all or part of the esophagus, necessitates significant lifestyle adjustments, particularly in dietary habits. This article provides comprehensive guidelines for managing your diet after an esophagectomy, aimed at minimizing discomfort, preventing complications, and ensuring adequate nutrition for optimal healing and recovery.
Understanding Esophagectomy and Its Impact on Digestion
Esophagectomy involves removing the esophagus, the crucial tube that transports food from the mouth to the stomach. To maintain the food passageway, the stomach is repositioned and reattached, often stretching it into the chest. This alteration reduces the stomach's capacity, affecting the ability to consume large meals. Nutrition becomes a critical aspect of recovery, focusing on preventing weight loss and managing potential complications like nausea, vomiting, acid reflux, and dumping syndrome.
Initial Post-Surgery Expectations
Immediately following the surgery, patients typically rely on a feeding tube for nutrition, potentially for up to two months. The transition involves progressing from a liquid diet to soft foods before gradually reintroducing most pre-surgery foods. The recovery period can extend up to two years as the body adapts.
Eating and Drinking Adaptations
Post-esophagectomy, the digestive system requires adjustments in eating frequency and portion sizes. Due to the shortened digestive tract, more frequent, smaller meals are recommended over three large meals. Slow eating, thorough chewing, and cutting food into small pieces are essential to prevent indigestion symptoms such as heartburn.
Diet Basics After Esophageal Surgery
Following an esophagectomy, the primary dietary goal is to maximize caloric intake while minimizing discomfort.
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General Recommendations:
- Consume soft, moist foods that are easy to swallow.
- Take small bites and chew food thoroughly.
- Try eating 6 small meals and snacks throughout the day, rather than 3 larger meals.
- Drink 6-8 eight-ounce glasses of fluids daily.
- Stop eating when you start to feel full.
- Take a daily multivitamin. A chewable multivitamin is usually well-tolerated. You can take either one adult or two children’s chewable vitamins. A calcium supplement may be indicated - ask your surgeon.
Foods to Avoid:
- Tough, fibrous, or grisly meats.
- Soft Bread/Rolls
- Foods that cause discomfort.
- Acidic foods (citrus fruits/juices, tomatoes and tomato products).
- Peppermint, and salty or very hot or very cold foods.
Managing Common Post-Esophagectomy Symptoms
Patients often experience various gastrointestinal symptoms after an esophagectomy. Adjusting dietary habits can significantly mitigate these issues.
Heartburn and Reflux Prevention:
- Avoid tight-fitting clothing and frequent bending.
- Elevate your bed to 6 inches when sleeping.
- Limit caffeine intake (coffee, tea, and cola drinks).
- Limit fatty foods.
- Avoid chocolate.
- Avoid acidic foods (tomatoes, vinegar, hot peppers, and citrus fruits).
- Avoid spearmint and peppermint.
- Avoid carbonated beverages.
- Limit or avoid alcohol.
- Avoid eating both extremely hot or cold foods.
- Sit upright after eating and remain in a sitting position for 45-60 minutes after eating.
- Do not eat for 2 hours before bed.
Reducing Gas and Bloating:
- Avoid foods that may cause gas and bloating like beans, broccoli, Brussels sprouts, cauliflower, cabbage, corn, garlic, lentils, turnips, onions, scallions, peas, sauerkraut, soybeans, apples, avocados, watermelon, cantaloupe, honeydew melon, beer, and nuts.
- Avoid "air swallowing" activities: using straws, slurping foods, chewing gum, and drinking carbonated beverages.
Addressing Dumping Syndrome
Dumping syndrome occurs when undigested food passes too rapidly from the stomach into the small intestine.
Symptoms: Nausea, feelings of fullness, crampy abdominal pain, followed by diarrhea (usually within 15 minutes of a meal). Some individuals may also experience low blood sugar (reactive hypoglycemia) 1 to 2 hours after meals, which may cause weakness, nausea, sweating, hunger, fast heart rate, anxiety, and shaking.
Tips to Avoid Dumping Syndrome:
- Drink liquids 30 to 60 minutes before or after meals and limit it to ½ to 1-cup servings. Choose unsweetened liquids (100% fruit juice may be diluted).
- Drink six to eight 8-ounce glasses of non-caffeinated beverages daily. Carbonated beverages should be avoided initially, as they may cause gas and bloating.
- Eat small, frequent meals. If you experience discomfort after eating, decrease your portion sizes or number of foods eaten at one time. Try to eat three small meals and three between-meal snacks. The evening snack should be eaten 2 hours before bedtime.
- Relax at mealtimes, eat slowly and chew your food well.
- All food and drink should be moderate in temperature. Avoid very cold or frozen foods and very hot foods.
- Initially, you may experience lactose intolerance (the inability to digest milk sugar). Try small amounts of milk to determine tolerance.
- The diet should be moderate in fat (fat slows stomach emptying), high in protein, and low in simple carbohydrates (sugar, sweets).
- If your appetite is poor and weight loss occurs, a liquid supplement may be used. Examples include Ensure® or Boost®, which contain sugar. If avoiding sugar or sweets, Diet Carnation Instant Breakfast® (which contains milk), Boost Glucose Control® or Glucerna®.
- Eat a variety of foods to assure adequate amounts of vitamins, minerals, calories, and protein to meet your needs and prevent weight loss. A multivitamin is recommended.
The Role of Feeding Tubes
Post-esophagectomy, a feeding tube (Jejunostomy or "J-Tube") is often necessary to provide extra nutrients and promote wound healing.
Feeding Tube Management:
- Feeding Tube Usage: Many patients find that putting the J-Tube feeds on at night while sleeping and off during the day works well.
- Home Arrangements: A social worker will work closely with you and your family to start arranging for the feedings and for the necessary equipment to be sent to your home in the early postoperative period.
- Care and Maintenance: Your floor nurse will teach you and your family all you need to know regarding tube feeding at home and the care of your J-Tube.
- Local Irritation: J- Tubes often show signs of local irritation (some redness and drainage) at the insertion site, which can often be confused with infection. Do not be concerned about this.
- When to Call Your Surgeon: Things to look for include increasing redness around tube site, frank pus from around tube site, new pain around the tube site and fever. You should call your surgeon's office immediately if you develop any of these symptoms.
- Tube Dislodgement: If your J-Tube comes out at any time after you are discharged, it is very important that it be replaced within a few hours so that the "track" does not close up.
Post-Esophagectomy Diet Progression
Clear Liquid Diet
You will start a clear liquid diet around 6 days after your surgery. To learn more about what you can drink while following this diet, read the “Clear liquid diet” section near the end of this resource.When you first start following a clear liquid diet, your tube feeding schedule will be shortened from about 24 hours per day to about 18 hours per day. When you’re discharged home, your tube feeding schedule will be shortened to about 16 hours a day, depending on your progress. This will help increase your appetite during the day.Drink small amounts at a time and drink slowly as you learn your limits. This will help you keep from having reflux. Start with 4 ounces (½ cup) at a time. Aim to drink 4 ounces of liquids 6 to 8 times a day (24 to 32 ounces total) when you first start a clear liquid diet.
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Full Liquid Diet
If you’re able to follow a clear liquid diet, you will start following a full liquid diet around 10 days after your surgery. To learn more about what you can drink while following this diet, read the “Full liquid diet” section near the end of this resource.When you start following a full liquid diet, your outpatient clinical dietitian nutritionist will give you instructions for how to adjust your tube feeding schedule. Most people keep the same tube feeding rate but lower the number of hours they get tube feeds to 12 hours per day.You may not be able to drink some or all dairy products after your surgery. Pay attention to the way you feel after having dairy (such as milk and yogurt), and avoid the things that cause discomfort.
Soft Diet
Your outpatient clinical dietitian nutritionist will tell you when you should start following a soft diet. Usually, this is around 13 days after your surgery. For information about what you can drink and eat while following this diet, read the “Soft diet” section near the end of this resource. You can also follow the 6-meal soft diet sample menus included in that section.When you start following a soft diet, your outpatient clinical dietitian nutritionist will give you instructions for how to adjust your tube feeding schedule. Most people keep the same tube feeding rate but lower the number of hours they get tube feeds to 8 hours per day.When you start following a soft diet, you should also start tracking your weight and keeping a food and drink log.You may not be able to eat some foods that you could eat before surgery, such as sweets and dairy. Pay attention to the way you feel after eating different foods and keep notes in your log.
The Importance of Early Oral Feeding
There is some controversy surrounds the postoperative feeding regimen utilized in patients who undergo esophagectomy. Some institutions have embraced the practice of enhanced recovery after surgery (ERAS) programs, with variation in practice related to early introduction of oral intake. Recent evidence suggests that early oral feeding is associated with shorter LOS, faster return of bowel function, and improved quality of life.
Benefits of Early Oral Feeding:
- Shorter Hospital Stay: Studies have shown that patients who start eating sooner after surgery tend to leave the hospital earlier.
- Faster Bowel Function Recovery: Early feeding can stimulate the digestive system, leading to a quicker return of normal bowel movements.
- Improved Quality of Life: Being able to eat and enjoy food sooner can positively impact a patient's overall well-being.
- Cost-Effectiveness: Streamlined recovery can translate to lower healthcare costs.
Potential Risks and Considerations:
- Anastomotic Leaks: There is some evidence associating early feeding with increased anastomotic leaks.
- Location of anastomosis: Location of anastomosis (cervical vs intrathoracic)
- Surgical approach: Surgical approach (open vs minimally invasive).
Long-Term Nutritional Strategies
Maximizing Caloric Intake:
The goal of your diet when you first go home is to maximize caloric intake while minimizing discomfort as you begin to eat. Ideally, meals should be moist in consistency.
Eating Small Meals:
Since the capacity of your stomach is reduced after the surgery, you should eat small but frequent meals (four to six times per day) - for example, three main meals and two snacks. Do not force yourself to eat to the point of discomfort. Stop eating immediately when you feel full.
Read also: Weight Loss with Low-FODMAP
Mild Flavors:
Food should be mild in taste. Avoid foods that irritate the digestive tract, such as caffeine-containing beverages, alcohol, ground pepper (white and black), chili powder, and hot, spicy foods. If you experience pain or a burning sensation upon swallowing, also avoid the following: acidic foods (citrus fruits/juices, tomatoes and tomato products), peppermint, and salty or very hot or very cold foods.
Moist Foods:
For ease in swallowing, select moist foods that stay together easily without falling apart, yet will not stick to the roof of your mouth or gums. Use small amounts of gravy, sauce, butter or margarine to help moisten foods. Take small bites of food and chew thoroughly before swallowing. Sip small amounts of liquids slowly with meals if necessary to soften food. It is recommended not to exceed 4 ounces (1/2 cup) at a meal.
Avoiding Fluids During Meals:
Avoid large amounts of fluids during meals, as these will fill you up quickly and may prevent you from eating other nutritious foods. Liquids may be taken between meals (1/2 to 1 hour after eating). Try to drink thick, nutrient-dense liquids rather than thin, clear liquids. To minimize gas, avoid drinking carbonated beverages, sucking on candies, chewing gum and using straws.
Staying Upright After Meals:
To avoid discomfort, remain sitting for at least an hour after meals. Elevate the head of your bed; gravity helps to keep stomach contents down. Generally avoid dry breads (such as bagels), dry meats and steaks (unless they are easy to chew) and carbonated beverages.
Rehabilitation and Exercise
While exercise may be unappealing during recovery, it's crucial for preventing blood clots. Initially, brief, frequent walks are recommended. Adhering to healthcare provider instructions regarding safe activities is essential, as even light lifting can be detrimental during recovery.
Hygiene and Wound Care
Initially, sponge baths may be necessary. Healthcare providers will advise on transitioning to showers or baths. Cleaning around the feeding tube and wound, along with monitoring for infection signs (bleeding, drainage, redness, warmth), are critical aspects of hygiene.
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