Gerd and post op mgmt. dr. blatchford 1.2014


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Gerd and post op mgmt. dr. blatchford 1.2014

  2. 2. OBJECTIVES Understand from the surgical perspective what operation was performed and how to troubleshoot  Identify key points of what information is important to the surgeon when calling about a patient  Understand early signs of possible serious complications and possible causes 
  3. 3. GASTROESOPHAGEAL REFLUX DISEASE (GERD) 1. Definition  b. GERD common, affecting 15 – 20% of adults  c. 10% persons experience daily heartburn and indigestion  d. Because of location near other organs symptoms may mimic other illnesses including heart problems  a. Gastroesophageal reflux is the backward flow of gastric content into the esophagus.
  4. 4. GASTROESOPHAGEAL REFLUX DISEASE (GERD) 2. Pathophysiology  a. Gastroesophageal reflux results from transient relaxation or incompetence of lower esophageal sphincter, sphincter, or increased pressure within stomach  b. Factors contributing to gastroesophageal reflux 1.Increased gastric volume (post meals) 2.Position pushing gastric contents close to gastroesophageal juncture (such as bending or lying down) 3.Increased gastric pressure (obesity or tight clothing) 4.Hiatal hernia
  5. 5. GASTROESOPHAGEAL REFLUX DISEASE (GERD) c.Normally the peristalsis in esophagus and bicarbonate in salivary secretions neutralize any gastric juices (acidic) that contact the esophagus; during sleep and with gastroesophageal reflux esophageal mucosa is damaged and inflamed; prolonged exposure causes ulceration, friable mucosa, and bleeding; untreated there is scarring and stricture 3. Manifestations  a. Heartburn after meals, while bending over, or recumbent  b. May have regurgitation of sour materials in mouth, pain with swallowing  c. Atypical chest pain  d. Sore throat with hoarseness  e. Bronchospasm and laryngospasm 
  6. 6. GASTROESOPHAGEAL REFLUX DISEASE (GERD) 4. Complications  a. Esophageal strictures, which can progress to dysphagia  b. Barrett’s esophagus: changes in cells lining esophagus with increased risk for esophageal cancer 5. Collaborative Care  a. Diagnosis may be made from history of symptoms and risks  b. Treatment includes 1.Life style changes 2.Diet modifications 3.Medications
  7. 7. GASTROESOPHAGEAL REFLUX DISEASE (GERD) 6. Diagnostic Tests  a. Barium swallow (evaluation of esophagus, stomach, small intestine)  b. Upper endoscopy: direct visualization; biopsies may be done  c. 24-hour ambulatory pH monitoring  d. Esophageal manometry, which measure pressures of esophageal sphincter and peristalsis  e. Esophageal motility studies
  8. 8. GASTROESOPHAGEAL REFLUX DISEASE (GERD) 7.Medications     a. Antacids for mild to moderate symptoms, e.g. Maalox, Mylanta, Gaviscon b. H2-receptor blockers: decrease acid production; given BID or more often, e.g. cimetidine, ranitidine, famotidine, nizatidine c. Proton-pump inhibitors: reduce gastric secretions, promote healing of esophageal erosion and relieve symptoms, e.g. omeprazole (prilosec); lansoprazole (Prevacid) initially for 8 weeks; or 3 to 6 months d. Promotility agent: enhances esophageal clearance and gastric emptying, e.g. metoclopramide (reglan)
  9. 9. GASTROESOPHAGEAL REFLUX DISEASE 8. Dietary and Lifestyle Management        a. Elimination of acid foods (tomatoes, spicy, citrus foods, coffee) b. Avoiding food which relax esophageal sphincter or delay gastric emptying (fatty foods, chocolate, peppermint, alcohol) c. Maintain ideal body weight d. Eat small meals and stay upright 2 hours post eating; no eating 3 hours prior to going to bed e. Elevate head of bed on 6 – 8 blocks to decrease reflux f. No smoking g. Avoiding bending and wear loose fitting clothing
  10. 10. GASTROESOPHAGEAL REFLUX DISEASE (GERD) 9.Surgery indicated for persons not improved by diet and life style changes  a. Laparoscopic procedures to tighten lower esophageal sphincter  b. Open surgical procedure: Nissen fundoplication 10. Nursing Care  a. Pain usually controlled by treatment  b. Assist client to institute home plan
  11. 11. HIATAL HERNIA 1.Definition   a. Part of stomach protrudes through the esophageal hiatus of the diaphragm into thoracic cavity b. Predisposing factors include:      Increased intra-abdominal pressure Increased age Trauma Congenital weakness Forced recumbent position
  12. 12. HIATAL HERNIA    c. Most cases are asymptomatic; incidence increases with age d. Sliding hiatal hernia: gastroesophageal junction and fundus of stomach slide through the esophageal hiatus e. Paraesophageal hiatal hernia: the gastroesophageal junction is in normal place but part of stomach herniates through esophageal hiatus; hernia can become strangulated; client may develop gastritis with bleeding
  13. 13. HIATAL HERNIA 2. Manifestations: Similar to GERD 3. Diagnostic Tests  a. Barium swallow  b. Upper endoscopy 4. Treatment  a. Similar to GERD: diet and lifestyle changes, medications  b. If medical treatment is not effective or hernia becomes incarcerated, then surgery; usually Nissen fundoplication by thoracic or abdominal approach  Anchoring the lower esophageal sphincter by wrapping a portion of the stomach around it to anchor it in place
  14. 14. NISSEN FUNDOPLICATION Average hospital stay 1-2 days  Resolution of symptoms at 1 year 94%  Major complications 2%  Long term complications 2-62% (gas bloat and difficulty swallowing)  Generally the larger the hiatal hernia, the greater the crural dissection. Patient may have subcutaneous air present for the 1st 48 hours post-op. 
  15. 15. TIF TIF (Transoral Incisionless Fundoplication) No incisions • No scarring • No incisional herniation • Less potential for infection nosocomial infection minimized Patient friendly • Rapid return to work and normal activities Unique Surgical Approach
  16. 16. 100% MEDICAL/SURGICAL THERAPIES • Lap Open • •TIF2 Fundoplasty Fundoplasty 50% Fundoplasty • • Medical Therapies PPI, H2 Lifestyle/Behavior Modifications Medical Therapies Incisionless TIF Fundoplication 50% 100%
  17. 17. TIF Experience Reconstructs the natural primary barrier to reflux by creating a robust valve     45 - 60 minute procedure Overnight stay (general anesthesia) Post-op discomfort minimal Rapid recovery – Most patients are back to work and most activities in a couple of days Unique Surgical Approach
  18. 18. Multi Center Trial (1 year) N=79 85% of Patients OFF daily PPIs • Minimal risk of adverse events • Excellent QOL improvement 73% • Elimination of PPI use 85% • Esophagitis resolution 59% • Hiatal hernia reduction 71% • pH normalization 49% (Hill grade one) Clinically Safe & Effective
  19. 19. Multi-Center Trial (2 years) N=79 • Minimal risk of adverse events • Patients satisfied: 86% • Patients can consume reflux causing foods without symptoms: 60-80% • No long-term adverse events Clinically Safe & Effective
  20. 20. BARIATRIC PROCEDURES Lap Band  Gastric Sleeve  Roux en Y Gastric Bypass 
  21. 21. LAP BAND      Least invasive Overnight stay Good weight loss production Requires filling and band adjustments 3-5% slippage rate
  22. 22. GASTRIC SLEEVE     Part of stomach is removed making a small reservoir for food Helps you lose weight with restrictive properties and stimulates the feeling of fullness Excellent safety profile Outpatient or only 24 hour stay in hospital
  23. 23. GASTRIC BYPASS    Creates small proximal gastric pouch that is connected to the jejunum bypassing the duodenum Causes weight loss with restrictive and malabsorbtive properties Hospital stay 2-3 days
  24. 24. POST OPERATIVE CARE Pain Control  Diet Protocol  I &Os  Ambulation  Patient stays on antireflux medication at least 2 weeks post operatively  Wound assessment 
  25. 25. MAJOR SURGICAL COMPLICATIONS AND CONCERNS             Pneumonia Myocardial infarction DVT or PE Wound infection Anastamotic leak Band Slippage Esophageal perforation or stomach perforation Pneumothorax Internal hemmorage Slipped nissen Internal hernia Wound dehiscence
  26. 26. TROUBLESHOOTING Persistent Tachycardia above baseline may be the earliest sign of a possible anastamotic leak  Patient population at even higher risk for DVT, MI, Post op pneumonia, atelectasis, and wound infection than the general population.  Early ambulation is key  For provider calls it is of utmost important to provide all vitals, trends, as well as wound assessment and I&Os. 
  27. 27. TROUBLESHOOTING         Decreased urine output (less than 30 cc per hour in the average adult) Persistent pain despite liberal use of narcotics Tachycardia Shortness of breath Sudden onset of subcutaneous air (however may be normal if extensive crural disection). Mild fever common postop if <101 F. Always assess the whole patient (not one single value), Including the wounds prior to assuming there is a problem. If it is a surgical patient, the surgeon should be called
  28. 28. IN SUMMARY Be paranoid  Be thorough with assessment  Be organized  Recognize early signs of possible life threatening complications  Effective communication. (Be focused and brief) 
  29. 29. QUESTIONS ????
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