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CTOP Retreat 2014
Esophageal Cancer Pathway
May 23, 2014
Introduction
•Esophageal cancer is the 7th leading cause of cancer
death.
•Incidence of esophageal cancer has increased faster
than any other solid tumor.
•Despite advances in diagnosis, staging and treatment,
the overall 5-year survival ranges from 15-30%.
•Surgery for esophageal cancer has a routine
complication rate of 50-75%.
In these discouraging numbers lies an
opportunity to have a meaningful and
measurable impact on patient care.
Mission: To provide a Dartmouth standard of care that surpasses
current national standards
Vision: Through the development of evidence-based clinical care
pathways, we create a program to provide the highest quality of care
for esophageal cancer patients
Aims:
1. To assess current needs of patients and resources
2. To build a team of providers invested in a shared clinical pathway
3. To map the flow of patients through treatment of esophageal
cancer
4. To optimize efficiency and evidence-based medicine
5. To track process and outcomes
Aim 1: To assess current needs of
patients and resources
1. List every contact with a DHMC service a patient with esophageal cancer may have
2. List all necessary studies (pathology, radiology, endoscopy) a patient may need, and
the optimal order of events
3. Mailed questionnaire to patients.
• “What did we do well?”
• “Where could we improve?”
4. Reunion of past patients
Aim 2: To build a team of providers
invested in a shared clinical pathway
1. Secretarial lead
2. Nurse navigator
3. Physician lead
4. Surgery-anesthesia
5. Quality-Electronic Medical Record
Aim 3: To map the flow of patients through
treatment of esophageal cancer
Palliative GI consult
(stent/ablation) as
needed
Mandatory
Palliative Care
consult
Mandatory medical
oncology consult
Stage IV
Palliative thoracic
surgery (J tube/G tube),
as needed
Initial Evaluation
Specialty referral
GI, Oncology
Scheduler books
coordinated
appointment
- Special Instructions:
Tuesday pm
dedicated new
patient consultation, - 2 appts reserved
Keep Tuesday pm
appointments clear
for esophageal
patients until Friday
NCCC- Thoracic
Oncology
PCP referral
Thoracic surgery
Radiation Oncology
Connect to
Thoracic
Onc,Scheduler,
NCCC
650-6344
If scheduler has
clinical questions
on who pt should
see, refer to Nurse
Navigator
Alternate to
NCCC: Thoracic
Scheduler
Alternate to
Nurse Nav.:
Physician
Assistant
GI
Other
Scheduler collects the
following before initial
appointment:
□Physician notes
□Endoscopy report
□Pathology report
□Pathology slides
□EUS report
□Imaging: CT/PET
All stages
On same day as
surgical consult, joint
appointment with:
Consult with Dr.
Erkmen to:
Nurse Navigator
contact prior to
visit, with phone
note asking
about smoking
status, weight
loss, and
transportation
needs
□Discuss stage and
treatment plan
□Receive patient
education binder
□Fill out questionnaire
□Receive patient
binder
Staging information
entered into eDH by
Ellen Parker at
Tumor Board
Presentation at
multidisciplinary
tumor board
Multidisciplinary
staging
designation
Stage II/III
Patient referred to DH Med Onc
(dedicated Tuesday afternoon appt
with Dr. Dragnev)
Appointment for
surgery booked
Pre-operative
Palliative Care
consult
Restaging Appointment
Surveillance with
Med Onc
□Cardiac assessment,
Patient would
benefit from
Shared
Decision
consult
Stage I
Proceed with
surgery
No
Yes
□Bloodwork
□Chest xray
□Abx
□Heparin
Yes
Need for
feeding tube
Yes
□Extra mayo stand for laparoscopy
□Waterproof gown
□Extra ioban for sleeves
Review plan morning of
surgery with Pain Service
□Dietician
□ Patient fills out
□Signed consent
□DPOA submitted
□Advanced directives
and care planning
submitted
□VNA selected
□Rehab selected
3 weeks after last
treatment, pelvic,
abd, chest CT
Restaging Appointment
Check in
appointment with Dr.
Erkmen 3 weeks
after completion of
last treatment
Screening for
Shared Decision
Making, screening
questions entered
into Nurse Navigator
note
Good sx
candidate?
On same day as
surgical consult,
joint appointment
with:
□MSW
□Nurse navigator
□Smoking
cessation
□Dietician
Chemo/Radiation
recovery period
lasting 6-8 weeks
Metastatic
disease
accommodate liver retractor and
eschelon
In-room time documented
Pneumoboots placed
Two bovie pads placed
Foley with temp probe
Left lateral decubitus
Pillow between legs
Time out to include glucagon,
communication with ICU
Prep and drape
Chest surgery start
time documented
Chest surgery stop
time documented
3 to put through 12mm port
□28f chest tube
□3-0 vicryl to close ports
□Carter port closing device
□Glucagon 2mg to anesthesia
□Linear 75 green load stapler
□Jejunostomy tube prepared and
□Camera port anteriorly
□Harmonic port
□Azygous port
□Counter traction port
□Anterior traction of lunch
□Harmonic and thoracoscopic
flushed in alcohol, then flushed with
sterile saline solution
Call ICU fellow
to secure bed
Bronch
□Epidural
□Double lumen (left sided, check placement)
□A-line and Central line
□Subcutaneous heparin
□Preop antibiotics: 1.5g cefuroxine and 500mg
Placement of
18F NGT
debakey pleura
No
Evidence of
residual
disease
PET, EUS
No
Follow-up with
Med Onc
No
□Liberal clipping of lymphatic and
vascular attachments
Yes
Palliative Care
consult
□Turn start time documented
□Turn to supine
□Reposition to bottom of bed
□Place legs in stirrups
□Left arm tucked, right arm out
□Roll under neck for extension
□Replace EKG pads prep
□End turn time documented
□Resection of level 4,7,8,9 lymph
nodes for permanent
□Dissect thoracic duct between aorta,
azygous and esophagus
□Clip off thoracic duct
□28F straight chest tube placed
□Lung reinflated under thoracoscopic
□45 vascular stapler around azygous
view
□Penrose to encircle esophagus
□Ports closed 2-0 vicryl x2 and 4-0
□Dissection above azygous keeping monocryl
pleura intact
□Chest tube placed to suction
□Cut and leave Penrose at proximal
□Bovie, suction, camera, harmonic
esophagus
marked cords and saved
□Dissection to hiatus
□Dermaflex
Follow-up with
Med Onc
□Document neck start time
□Left neck incision along
□Drape
□Start abdomen surgery
□Posterior dissection
□Ensure suction to check
posteriorly to vertebral body
tube and pneumoboots on
□Staple drape to blue towels
□Cut hole for neck
□Secure bovine x2
□Secure suction, camera, insufflation,
□Take hepato-gastric ligament
□Take left gastric artery with 45 vascular
stapler
□Dissect lesser curvature to pylorus keeping
vasculature intact
harmonic
□Midline laparotomy
□Place Alexis hand port
□Insufflate through hand port
□Place 12mm left lateral port for camera and
switch
□Place 12mm left lateral port for harmonic
□Place 12mm right liver port
□Find gastroepiploic
□Take short gastric arteries to hiatus with
harmonic
□Take omentum distal to gastroepiploic,
palpating pulse
□Extend dissection to pylorus,
gastroduodenal posterior to pylorus
Send esophagus to
pathology with
proximal margin
looking for malignancy
and Barrett’s
sternocleidomastoid
documented
□Feel for NGT
□Pull NGT back to intra thoracic
esophagus
□Identify crow’s foot
□Mark esophagus with purple
pen
□Dissection to pull
Penrose up
□Dissect vascular bundle off
lesser curve
□Push esophagus
□Remove liver retractor 45-
□Divide esophagus
with linear 75 green
loads
□Kocher maneuver
□Test pylorus to hiatus
□Circumferentially dissect esophagus to
vascular staple across lesser
curve vascular bundle
hiatus
stomach to shape conduit
□Encircle esophagus at hiatus
□Enlarge hiatus
□Suture chest tube to proximal
□Double check NGT
□Eschelon-60 green loads across
from abdomen, pull
from neck
□Take lymph nodes
and esophagus with alis
□Place jejunostomy tube
□Witzel jejunostomy tube
and tack distally
□Test jejunostomy tube
from specimen
stomach stump with 0-silk sutures
□Give glucagon
□Pull NGT back to prevent it
Switch to single
lumen tube with
anesthesia attending
Right lung
deflated
□Hold gastric conduit
Intra-operative
legs
Thoracic Surgery
(Dr. Erkmen)
□Axesis wound protector
□Three 12mm ports, bladed which
□Fan liver retractor
□Eschelon stapler
□Extra purple marker for marking
□0-silk suture on SH cut to 15cm x
cessation
Pre-op Preparedness :
Anesthesia Consult :
□Pain Management
□Pre-op assessment
□Intra-operative
□ICU care
questionnaire
Scheduler calls
patient to check
in 10 weeks
after initial
evaluation
appointment
No
□Bertchold bed
□CO2 filled
□Pick list
□Bean bag match
□Harmonic
□Penrose
□45 Vascular stapler
□Endoscopic clip applier
□Two bovie pads and bovies
□Stapler for draping supine
□Two extra half sheets for stirrup
□MSW
□Nurse navigator
□Smoking
including EKG, option for
echo
Yes
Preop Checklist
On same day as
surgical consult,
joint appointment
with:
Appointment with Thoracic
Surgery (Dr. Erkmen)
Pre-operative
Shared
Decision
Making
consult
Yes
Chemo and Radiation
lasting 8-12 weeks
Patient referred to DH Rad Onc
(dedicated Tuesday afternoon appt
with Dr. Zaki)
with dietary by
Thoracic/NCCC
scheduler
Opt out
Intra-operative
Patient seen at
DHMC for
chemotherapy/
radiation therapy
Stage I
Stage II/III
Pt to receive
concurrent
chemotherapy and
radiation therapy at
DH or local hospital
No
□MSW
□Nurse navigator
□Smoking cessation
□Direct scheduling
from being stapled during
division of the esophagus
flagyl, clinda for alternative
Post Op Day 3
Neruo: epidural, PCA
CV: telemetry, watch for afib
Respiratory: chest PT and deep
breathing, chest tube to water seal if
no leak
Neck JP ensure holding bulb suction
GI: NPO/NGT to low wall suction,
flush every 30 cc to ensure patency
J tube to gravity, flush with 30 cc
every 8 hours, GI prophylaxis
GU: Keep ins and outs even, pt
should start to self-diurese, heplock
IV, balance electrolytes based on labs
Heme: sq heparin bid, CBC
ID: no antibiotics
Tubes/Lines/Drains: obtain PICC
line, d/c triple lumen catheter, d/c aline, Neck JP, chest tube, NGT, J
tube
Activity: ambulating, PT consult
Disposition: transfer to floor
Post Op Day 2
Neruo: epidural, PCA
CV: telemetry, keep SBP > 100, avoid pure
alpha agents for pressors
Respiratory: chest PT and deep breathing,
chest tube to water seal if no leak
Neck JP ensure holding bulb suction
GI: NPO/NGT to low wall suction, flush every
30 cc to ensure patency
J tube to gravity, flush with 30 cc every 8
hours, GI prophylaxis
obtain albumin/prealbumin, start TPN for
prealbumin < 20
GU: Keep ins and outs even, decrease all IVF
to sum of 75 cc/hour, balance electrolytes
based on lab
Heme: sq heparin bid, CBC
ID: ensure d/c of perioperative antibiotics
Tubes/Lines/Drains: Keep triple lumen, keep
a-line, Neck JP, chest tube, NGT, J tube
Activity: ambulating, PT consult
Disposition: ISCU, but can transfer to floor if
doing well
Post Op Day 4
Neruo: epidural, PCA
CV: telemetry, watch for afib
Respiratory: chest PT and deep
breathing, chest tube to water
seal, check for leak of chyle or
bile, Neck JP ensure holding bulb
suction
GI: If + flatus, D/C NGT, J tube
feeding, 20 cc/hour to increase by
20 cc every 8 hours as tolerated
to a maximum 100 cc/hour
GU: pt should be negative for the
day, balance electrolytes based
on labs
Heme: sq heparin bid, CBC
ID: no antibiotics
Tubes/Lines/Drains: PICC line,
Neck JP, chest tube, J tube
Activity: ambulating, PT consult
Disposition: floor alert CRC of
possible discharge on POD #8-14
Post Op Day 5,6
Neruo: epidural, d/c PCA, liquid
roxicette via j tube
CV: telemetry, watch for afib
Respiratory: chest PT and deep
breathing, chest tube to water seal,
looking for chyle and bile, Neck JP
ensure holding bulb suction
GI: tube feeds to 100 cc/hour x 20
hours,
GU: achieve baseline weight and even
fluid balance for hospitalization, may
need diuresis, balance electrolytes
based on labs
Heme: sq heparin bid, CBC
ID: no antibiotics
Tubes/Lines/Drains: PICC line, Neck
JP, chest tube, J tube
Activity: ambulating, PT consult
Disposition: floor, alert CRC of
possible discharge on POD #8-14,
prepare for rehab or home with VNA,
prepare for tube feeding
Post Op Day 8
Neruo: liquid roxicette via j tube, make sure
patient has liquid roxicette (bottle, not
just Rx) for home
CV: d/c telemetry,
Respiratory: D/c chest tube and jp if no
evidence of leak after drinking clears
GI: advance to clear liquid diet, make
sure nutrition educates patient on diet,
albumin/prealbumin shortly before
discharge, resume home meds crushed
and given P.O., j tube teaching, tube feeds
to 100 cc/hour x 20 hours
GU: achieve baseline weight and even fluid
balance for hospitalization, may need
diuresis, balance electrolytes based on
Heme: sq heparin bid,
ID: no antibiotics
Tubes/Lines/Drains: PICC line,, J tube
Activity: ambulating, PT consult
Disposition: floor, alert CRC of possible
discharge on POD #8-14, prepare for rehab
or home with VNA, prepare for tube feeding
Post Op Day 7
Neruo: d/c epidural, liquid roxicette via j tube
CV: telemetry, watch for afib
Respiratory: chest PT and deep breathing,
chest tube to water seal. Neck JP ensure holding
bulb suction
GI: obtain swallow study to rule out
anastomotic leak and evaluate gastric
emptying, can start sips of clears if swallow
study is favorable, d/c TPN if tolerating tube
feeding, tube feeds to 100 cc/hour x 20 hours
GU: achieve baseline weight and even fluid
balance for hospitalization, may need diuresis,
balance electrolytes based on labs
Heme: hold sq heparin in expectation of epidural
removal, CBC
ID: no antibiotics
Tubes/Lines/Drains: PICC line, Neck JP, chest
tube, J tube
Activity: ambulating, PT consult
Disposition: floor, alert CRC of possible
discharge on POD #8-14, prepare for rehab or
home with VNA, prepare for tube feeding
Rehab
Discharge
Neruo: liquid roxicette via j tube, make
sure patient has liquid roxicette (bottle,
not just Rx) for home
GI: clear liquid diet, tube feeds to 100
cc/hour x 20 hours
Tubes/Lines/Drains: d/c PICC line, J
tube
Disposition: home/rehab with follow up in
2 weeks with a CXR in Dr. Erkmen’s clinic
Recovery in Rehab
on tube feeds
Discharge Plan
□Diet
□F/U appt with Dr. Erkmen in
Pain
management
questions
2 weeks
□ Copy of discharge to PA,
NP, Nurse Navigator, Linda
Mason, and Nutrition Services
□ Copy of discharge to PCP
Post Discharge
Weeks 2-12:
Office visits every
2-3 weeks for
weight checks,
wound checks,
chest xrays,
gradually advance
diet
Post Discharge
Week 12:
Remove feeding
tube, discuss
return to work
(depending on
occupation)
Follow up with Esophageal
Cancer Clinic as needed and
attend Esophageal Reunion
Meetings every 6 months. Fill out
questionnaire
Yes
and referring physicians
Home
No
Recovery at Home
on tube feeds
Call PA and/or NP
650-8537
Post-operative
Post-operative
Overnight in ICU
Post Op Day 1
Neruo: epidural, can start PCA if awake
CV: Continue telemetry, keep SBP > 100,
avoid pure alpha agents for pressors
Respiratory: Extubated, chest PT and
deep breathing, chest tube to -20
Neck JP ensure holding bulb suction
CXR to monitor conduit and lungs
GI: NPO/NGT to low wall suction, flush
every 30 cc to ensure patency
J tube to gravity, flush with 30 cc every 8
hours, GI prophylaxis
GU: Keep ins and outs even, avoid fluid
overload, maintenance IVF, balance
electrolytes based on labs
Heme: sq heparin bid
ID: Complete antibiotics for prophylaxis
Tubes/Lines/Drains: Keep triple lumen,
keep a-line, Neck JP, chest tube, NGT, J
tube
Activity: up in chair
Disposition: can transfer to ISCU if doing
well
Aim 4: To optimize efficiency and evidencebased medicine
• Identify optimal, evidence-based practices
• Identify opportunities to
– Educate patients
– Educate providers
– Reorganize current resources
Aim 5: To track process and outcomes
• Retrospective chart review of pathway
patients
• Compare to previous consecutive
esophagectomy patients
Pathway vs. Controls
• No
demographic
differences
Immeasurable Benefits
• Patient connection with providers
• Providers working as a team with equal voice
• Identify deficiencies
Limitations
• Few patients
• Maintenance of pathway
• Resources
Future Directions
• Pathway integrated with database
• Pathway manager?
Thank You
Questions?
To personalize the experience of each patient
treated for esophageal cancer at DHMC-NCCC
• Patient Binder
• Patient Video
• Shared Decision-making
Shared Decision-Making
Learning about
esophageal cancer
Obtaining high quality
information about
available options, the
pros and cons
Decision based on
what is important to
you.
Learning about esophageal cancer
•The esophagus is a muscular tube connecting
the mouth and the back of the throat (pharynx)
to the stomach.
•Normal cells of the esophagus grow and divide
to replace old or damaged cells
•Sometimes this process goes wrong. New cells
form when the body does not need them or
damaged cells do not die as they should. The
buildup of extra cells forms a mass of tissue
called a tumor
•Esophageal cancer begins in the inner layer of
the esophagus. Over time, the cancer may
1. invade more deeply into the esophagus
2. Spread to nearby lymph nodes*
3. Spread to other parts of the body
*Lymph nodes normally act as filters. They filter out
infection and cancer. Often, esophageal cancer will
spread to lymph nodes before spreading to other parts
of the body
Thank You