gerd and post op mgmt. dr. blatchford 1.2014
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GERD AND BARIATRIC POST OPERATIVE MANAGEMENT
Patrick T. Blatchford, MD, FACS
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
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.
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
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
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 changes2.Diet modifications3.Medications
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
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)
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
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
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
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
HIATAL HERNIA
2.Manifestations: Similar to GERD3.Diagnostic Tests a. Barium swallow b. Upper endoscopy4.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
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.
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
MEDICAL/SURGICAL THERAPIES
Medical Therapies
50
%
50%0%
•Medical Therapies PPI, H2
• Lap Fundoplasty
Open • Fundoplasty •TIF2
Fundoplasty 1
00
%
100%
Incisionless TIFFundoplication
•Lifestyle/Behavior Modifications
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
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
Multi-Center Trial (2 years) N=79
Clinically Safe & Effective
• Minimal risk of adverse events
• Patients satisfied: 86%
• Patients can consume reflux causing foods without symptoms: 60-80%
• No long-term adverse events
BARIATRIC PROCEDURES
Lap Band Gastric Sleeve Roux en Y Gastric
Bypass
LAP BAND
Least invasive Overnight stay Good weight loss
production Requires filling and
band adjustments 3-5% slippage rate
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
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
POST OPERATIVE CARE
Pain Control Diet Protocol I &Os Ambulation Patient stays on antireflux medication
at least 2 weeks post operatively Wound assessment
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
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.
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
IN SUMMARY
Be paranoid Be thorough with assessment Be organized Recognize early signs of possible life
threatening complications Effective communication. (Be focused
and brief)
QUESTIONS ????