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GPs can help with post-operative problems

What sort of problems may these patients bring to their GP post-operatively?

Poor appetite, vomiting, regurgitation and the inability to eat large meals are common in the early post-operative period and can result in continued weight loss.

These symptoms may be due to the reduced volume of the stomach and its position in the chest, but in addition it often empties slowly due to vagal nerve destruction. Patients need to be advised to eat smaller meals with regular snacks in between. They should avoid eating late in the evening and may need to sleep propped up to prevent regurgitation.

Dysphagia is not uncommon from benign anastomotic structuring and may need several dilatations in the early post-operative period. Another affect of vagus nerve destruction during surgery is post vagotomy syndrome or 'dumping'.

For the majority of patients this manifests itself as post-prandial flushing and feeling dizzy and faint and loose bowels with urgency. These symptoms generally settle over a few months and with dietary manipulation such as avoiding liquids and reducing carbohydrates and sugar with meals. Diarrhoea or loose bowels and urgency may need loperamide hydrochloride or codeine to control.

Some patients have severe intractable symptoms that, along with abdominal pain, can make life very unpleasant. In these patients we have found the somatostatin analogue octreotide, injected subcutaneously shortly before meals, can be very effective in alleviating these symptoms. It is not licensed for this application and I am not sure the mechanism of its action is known, but presumably it works by affecting splanchnic blood flow and intestinal hormones in some way.

How can you help with palliation when cure is obviously not possible?

Unfortunately, for the majority of patients with oesophageal cancer, palliative treatments are needed from the outset. Dysphagia is probably the most common complaint of patients with advanced oesophageal carcinoma and so a lot of palliative treatments are aimed at relieving this symptom.

The options are oesophageal stents (metal or plastic), which physically enlarge the lumen of the oesophageal obstruction; palliative chemotherapy or radiotherapy (that can shrink the tumour to improve swallowing); or local ablative treatments to the lumen of the oesophagus, such as laser, argon ablation, intramucosal injection of alcohol, or intra-cavity radiotherapy. All the ablative treatments aim to cause local intra-luminal destruction of the tumour. The swallowing produced by an oesophageal stent, while adequate for soft foods and liquids, is certainly not normal, and, if chemotherapy or radiotherapy produces significant tumour regression, this may give them better palliation.

The individual choice depends very much on the local expertise and the overall condition of the patient. In addition some patients need more than one treatment modality, for example a patient may start with palliative chemotherapy but tumour progression may necessitate the need for an oesophageal stent.

Other aspects to palliative care are very important too. Not only traditional pain and symptom management but also the patient's social, psychological and spiritual support that will usually involve their GP and the hospice. Increasingly the appointment of specialist oesophageal support nurses can greatly help in this aspect of patient care.

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