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. 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. 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. 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.
7.
8.
9. 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
10. 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
11. 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)
12. 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
13. 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
14. 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
15. 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
16. 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
17. 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.
18. 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
19. 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%
20. 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
21. 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
22. 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
25. 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
26. 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
27. POST OPERATIVE CARE
Pain Control
Diet Protocol
I &Os
Ambulation
Patient stays on antireflux medication at least
2 weeks post operatively
Wound assessment
28. 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
29. 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.
30. 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
31. IN SUMMARY
Be paranoid
Be thorough with assessment
Be organized
Recognize early signs of possible life
threatening complications
Effective communication. (Be focused and
brief)
