Nutrition

Your esophagus is the tube that connects your throat to your stomach. Food enters your stomach through your esophagus. An esophagectomy is a surgery that removes part or all of this tube. Your stomach is often pulled up so there is no longer a long distance for your food to travel after you swallow. This makes it difficult to eat a lot of food a one time. After an esophagectomy, you need to change what and how you eat so you can be as healthy as possible.

How should I eat after my surgery?

Here are ten guidelines to help you maximize your nutrition and adjust to a new eating style.

Chew all food really well.

• Remember that digestion begins in the mouth. The smaller the food particles, the easier they will go down
• If it feels as if food is still getting stuck, sip water or another liquid with meals to encourage food to go down

Avoid foods that tend to be difficult to swallow.

• Soft breads and rolls have a tendency to get stuck.
• Tough, more fibrous meats such as steak should be avoided.
• Take note of specific foods that bother y The foods that are problematic are not the same for everyone.
• Choose soft foods with a sauce, gravy, or other liquid.
• Soups and stews are typically a good choice as long as meats are soft and cut into small pieces.
• Ground meats and soft protein choices such as eggs or cheese are also good options.
• Macaroni and cheese or other pasta dishes with a mild sauce are often well tolerated.

Eat small, frequent meals 5 or 6 times per day.

• After surgery, your stomach can hold much less food than before.
• Smaller meals will minimize discomfort and reduce risk for heartburn or reflux.

Introduce foods slowly.

• Some foods that were well tolerated before surgery may not be well tolerated now.
• If a food is not well tolerated, wait 1-2 weeks and try it again.

Drink at least six (8 ounce) cups of fluids per day.

• Sip fluids with meals and drink fluids in between meals to make sure that you stay properly hydrate
• Be careful not to drink too many fluids. If you are feeling too full to eat meals, decrease fluid int

Stop eating when you begin to feel full.

• Overeating will lead to discomfort from heartburn or reflux.
• It is ideal to stop eating after a small amount of food, and eat again 1-2 hours late

Eat to avoid reflux or heartburn.

• Wear clothing that is not tight fitting around your midsection
• Limit caffeine int Too much coffee, tea, and soda containing caffeine may trigger heartburn.
• Avoid chocolate, mint, vinegar, and hot pepper
• Creamy, higher fat foods made with cream or whole milk may trigger reflux.
• Citrus fruits/juices (orange, grapefruit, tangerine) and other highly acidic foods like tomatoes and tomato sauces may lead to heartburn
• Salty or extremely hot or cold foods may trigger heartburn
• Avoid alcohol
• Do not lie down after eating. Wait at least 3 hours before going to bed after eating.

Limit gas forming foods and behaviors.

• Gas forming foods include: broccoli, cauliflower, brussel sprouts, cabbage, corn, turnips, onions, peas, garlic, cantaloupe, watermelon, apples, avocado, beans, and lentils.
• Eliminate activities that involve swallowing extra air such as sucking on ice or candy, chewing gum, and drinking through a straw.
• Do not drink carbonated beverages.

Be aware of symptoms for dumping syndrome.

• Dumping syndrome is a condition where food that is not fully digested “dumps” quickly into the small intestine from the stomach.
• Dumping syndrome is accompanied by nausea, cramping, fullness, and diarrhea about 15 minutes after eating.
• You may experience a low blood sugar 1-2 hours after a m Weakness, sweating, hunger, shaking, and lightheadedness are all symptoms of a low blood sugar.
• If you have symptoms of dumping syndrome, it is best to consult a registered dietitian for the most individualized recommendations.

To reduce the risk of dumping syndrome:

• Drink only unsweetened liquids limited to ½ cup before or after meals
• Eat small and frequent meals
• Avoid extremely hot or cold foods
• Relax and eat slowly
• Eat lean, high protein foods with a small amount of added fat
• Avoid foods high in sugar
• Avoid foods that have a natural laxative effect such as caffeine, prunes, licorice,>figs and sugar alcohols
• Lying down for 20-30 minutes after eating may ease the symptoms of dumping syndrome Laying down does conflict with the recommendations for acid reflux. Use your best judgment as to which guidelines to follow based on your symptoms
• You may develop lactose intolerance associated with dumping syndrome. Avoiding dairy products (milk, cheese, ice cream, and yogurt) may ease gas, pain, bloating, or diarrhea as a result of not being able to digest lactose.
• Due to malabsorption of nutrients your surgeon may recommend a multivitamin or other nutrition supplement. It is best to consult with a registered dietitian for the most appropriate supplement recommendations

Which foods should I eat and which foods should I avoid after an esophagectomy?

• Choose pancakes, waffles, French toast, crackers, toasted bread
• Avoid breads with nuts, seeds, coconut or dried f Avoid highly seasoned crackers or breads (garlic, onion, etc.). Avoid sweet rolls, coffee cakes, and doughnuts.

Cereals

• Choose softer, easy-to-chew cereals, oatmeal, or cream of wheat.
• Avoid hard, coarse c Avoid high fiber cereals such as bran, barley, or granola.
• Avoid cereals with dried fruit, nuts, or coconut.

Desserts

• Choose cakes, pies, and cookies without nuts or chocolate. Try puddings, custard, ice cream, frozen yogurt, or sherbet.
• Avoid desserts made with chocolate, nuts, dried fruit, coconut, peppermint, or spearmint.

Drinks

• Choose water, caffeine-free tea, caffeine-free coffee, and mil Choose non-citrus juices such as apple, grape, and cranberry.
• Avoid carbonated drinks, alcoholic beverages, caffeinated drinks, or citrus juices such as orange, grapefruit, lemonade, or limeade.

Eggs

• Choose any type of eggs as long as they are not fried or heavily seasoned.
• Avoid deviled eggs and heavily seasoned egg salad.

Fats

• Choose butter or trans-fat free tub margarine, mayonnaise, mild salad dressings, olive or canola oil, or plain cream cheese
• Avoid highly seasoned salad dressings, cream sauces, gravies, bacon, bacon fat, ham fat, salt pork, lard, nuts, and fried foods

Fruits

• Choose canned fruit, cooked fruit, and non-citrus fruit juices.
• Avoid fresh fruits, dried fruits, ripe bananas, and fruits with seeds including berries and fig Avoid citrus fruits and citrus fruit juices.

Meats, Fish, Poultry, Cheese, and other protein

• Choose finely ground meats including beef, chicken, turkey, fish or lamb. Choose ricotta or cottage cheese, or mild cheeses such as Swiss, mozzarella, or America Try creamy peanut butter. Try plain yogurt without seeds.
• Avoid tough meats with hard fat. Avoid fried, heavily seasoned, or smoked meats including hot dogs, sausages, bacon, ribs, and lunch meats. Avoid anchovies, sardines, duck, goose, and shell fish such as clams and shrimp.
• Avoid strong, sharp, and hot pepper cheeses.
• Avoid chili and spicy Mexican food.
• Avoid crunchy peanut butter.

Starches

• Choose regular or sweet potatoes (peeled). Choose white rice, barley, and pasta.
• Avoid fried potatoes, potato skins, and potato chip Avoid fried rice, brown rice, and wild rice. Avoid popcorn.

Soups

• Choose mild soups and low-fat cream soup.
• Avoid heavily seasoned and tomato-based soup.

Sweets (If you have symptoms of dumping syndrome, avoid sweets entirely)

• Choose sugar, syrup, honey, jelly, seedless jam, and molasses. Try hard candy without fillings, nuts, or seeds.
• Avoid preserves, marmalade, and jams with seeds.
• Avoid marshmallows and any candy with nuts, seeds, dried fruit, coconut, peppermint, or spearmint.

Vegetables

• Choose cooked vegetables without seeds or skins including asparagus, peas, carrots, chopped spinach, beans, and winter squash.
• Avoid raw vegetables.
• Avoid tomato and vegetable juices.
• Avoid tomatoes and tomato sauces.
• Avoid broccoli, Brussel sprouts, cabbage, cauliflower, corn, cucumbers, onions,green pepper, radishes, rutabaga, turnips, beans and lentils because all these foods can cause gas.

Spices and Condiments

• Choose mild spices, herbs, and condiments as tolerated.
• Avoid heavy spices, chili sauce, barbeque sauce, horseradish, pepper, chili powder, onion, and garlic.

Cancer and cancer treatments can affect the way you eat and drink. Nutrition therapy, also known as nutrition support, involves finding ways to get nutrients and fluids when cancer or its treatment changes your ability to eat. Nutrition therapy is often used for a short time to help you heal while taking treatments or for a longer time if your ability to eat is permanently affected. The goal of nutrition therapy is to offer enough nourishment to avoid unhealthy weight loss and/or dehydration.

Who might need nutrition therapy?

• People who have significant weight loss due to low desire or difficulty eating
• People with low food intake for more than a week
• People who need to improve nutrition before a surgery

How is nutrition therapy given? (feeding types)

If the gastrointestinal tract (gut) is working and can still move food through the body, a feeding tube is used. An IV feeding is used if the gut does not work or is not working well.

Parenteral nutrition – Feeding through a large IV (intravenous catheter) into the bloodstream. Parenteral nutrition therapy is usually recommended when nutrition therapy will be required for a longer time.

Enteral nutrition – Feeding liquid nutrition through a tube into the stomach or intestines. Enteral nutrition therapy can be used for either a short or long time period.

An enteral feeding tube can be placed in a number of different locations depending on you and your health. The most common sites are described below.

• Nasogastric tube (NG tube or NGT) – A tube is inserted from the nose into the stomach
• Gastrostomy (G tube) – A tube is inserted from the skin surface directly into the stomach
• Jejunostomy (J tube) – A tube is inserted from the skin surface directly into the intestine

Where is nutrition therapy given?

While nutrition therapy may be used in a hospital setting, it is most often given at home through a nutrition therapy service (home health). If you or a loved one is thinking about home health, you may be worried about tube feeding or intravenous feeding. Either can be an intimidating thought. But with proper information and preparation, home feedings can be done and can even be rewarding. Below are some details to understand before you begin home feedings.

Formula

There are many different types of formula available. Each has certain components that are good for your nutritional needs. It is important to understand the amount (volume or feeding rate) and frequency (hang time) of the formula planned. Talk to your health care team about your feeding plan. Be sure to know where you can buy the formula and how it should be stored (some formulas need refrigeration).

Water Flushes

Water flushes clear the feeding tube and give you enough fluids. Know when flushes are needed (before, after, or during feedings) and how much water to use. It is important to follow the directions closely to prevent dryness or excess fluids.

Sanitation

Sanitation is very important in preventing infection and maintaining good health. Make sure to wash your hands properly before feedings. Also, wash the top of the formula can before opening to decrease possible contamination. Follow any other directions given by your health care team.

Sitting

Patients receiving enteral nutrition should try to sit up straight during tube feeding and for at least 30 minutes after feeding to stop backward flow of the food and possible aspiration (taking food particles or liquids into the lungs through the windpipe). If you are receiving parenteral nutrition, you do not need to worry about sitting.

Possible Side Effects

The benefits of nutrition therapy are often greater than the side effects, but you may have some problems. You will be able to handle some issues on your own, but always ask your health care team what they recommend. Be sure to have an emergency number to use when something happens outside your team’s regular office hours.

Possible Side Effects of Parenteral Nutrition:

• Infection: Infections can occur at the feeding site because of poor sanitation or can enter the body through the feedings if handled improperly.
• Overfeeding: Too much feeding can cause the body to receive more nutrients than needed which can lead to other issues such as overworking the lung
• Re-feeding syndrome: When a starved body receives feeding too quickly, issues can arise. If you have been without food or only taking a small amount, be sure to begin feeding slowly and with the direction of a health care team.

Possible Side Effects of Enteral Nutrition:

• Constipation: Difficult bowel movements due to lack of activity, poor fluids and fiber intakes, or use of pain medication.
• Dehydration: Lack of fluids that can be due to concentrated formulas, not enough free water flushes, too high protein intake, or high blood sugar levels.
• Diarrhea: Loose bowel movements that can be from medications, feeding too quickly, sorbitol-containing formula, or infection.
• Gastrointestinal reflux and aspiration: Reflux is the backward flow of gut contents into the throat. Aspiration results when these food items get into the lung This can lead to infection and pneumonia. Feeding while lying down is the most common cause. The bed should be elevated to at least 45°.
• High gastric residuals: Gastric residuals are the food particles that remain in the gut after feeding Your doctor or registered dietitian can assist if residuals are too high.

They may try to order a low-fat and low-fiber formula or decrease feeding rate.

• Malabsorption: Occurs when the gut can’t absorb the nutrients from food, which can lead to diarrhea and lack of proper nutrition
• Re-feeding syndrome: When a starved body receives feeding too quickly, issues can arise. If you have been without food or only taking a small amount, be sure to begin feeding slowly and with the direction of a health care team.

The immune system is weakened during all types of cancer treatment. Unfortunately, chemotherapy medications are not able to tell the difference between healthy cells and cancer cells. For this reason, perfectly healthy red and white blood cells are damaged or killed during treatment and shortly thereafter. The result of this is that body is not as good at fighting illness and infection. A common term used to refer to a very low neutrophil (white blood cell) count is neutropenia. Paying special attention to food safety during cancer treatment to reduce the risk of exposure to food borne illness may also be referred to a neutropenic diet. The following are some simple tips to reduce exposure and avoid unnecessary infection and/or illness during the time the immune system is compromised.

Keep EVERYTHING Clean

• Wash hands often and thoroughly especially before handling any food as well as after. Be sure to wash hands with warm water and soap for at least 20 seconds. Pay special attention to finger nails and the backs of the hands.
• Keep raw and cooked foods separate. Do not reuse any utensils, cutting boards, plates, dishes, once they have been touched by raw meat or eggs. Utensils, cutting boards, plates, dishes, etc. that have been used for preparing raw meats or eggs should be washed in hot, soapy water. It is best to keep separate cutting boards for meat and fruits/vegetables. Have an extra clean cutting board available for additional preparation as well.
• When shopping for and storing raw meats, keep them away from other foods and cover the packages with extra plastic wrap or use plastic bag This will prevent any liquids from leaking onto other foods or surfaces. Store meats and eggs toward the bottom of the refrigerator to prevent any dripping on other foods below.

Cook Food Thoroughly

• Avoid raw meat such as sushi, undercooked eggs (make sure eggs are at least “over easy” and not “sunny side up”), and other meats that have not been cooked to a proper internal temperature.
• Cook all eggs until both the white and the yolk are firm.

• Raw or undercooked meats
• Unpasteurized milk and juices
• Soft cheeses made with unpasteurized milk such as feta, blue cheese, Roquefort, Stilton, brie, or Farmer’s cheese
• Processed meats such as luncheon meats as well as anything else from a deli counter
• Refrigerated meat spreads or pâté
• Smoked fish or precooked shrimp or crab meat
• Sprouts such as bean sprouts, alfalfa sprouts, or broccoli sprouts
• Pre-cut fresh fruit and vegetables. Buy them whole, wash, and cut them yourself using proper sanitary techniques as outlined above.
• Unwashed fresh fruits and vegetables
• Unroasted or raw nuts and seeds
• Raw tofu or tempeh
• Food from salad bars of buffets
• “Fresh” salad dressings, salsas, sauces, e sold in the refrigerated section of the grocery store.
• Raw apple cider
• Raw honey
• Unrefrigerated cream filled pastries

The guidelines above were created with those who have severely weakened immune systems in mind. Consult your physician or healthcare team for regular updates on your blood counts and the status of your immune system.