Gerd and post op mgmt. dr. blatchford 1.2014

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.


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


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


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


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


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


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 ????

Health & Medicine

Gerd and post op mgmt. dr. blatchford 1.2014