Transcript Surgical Interventions in Gastroenterology

Laura Habighorst RN CAPA
Heartland Regional SGNA
April 27, 2011
Objectives
Identify common GI disorders that require surgical
intervention
2. Describe common surgical procedures performed for
GI disorders
3. Identify complications associated with surgical
interventions
4. Discuss nursing interventions related to treating
patients who have undergone surgery for GI
disorders.
1.
Gastroenterology Nursing: A Core Curriculum, 2008. Chapter 32: Surgical Interventions
Esophageal Disorders
Most common esophageal GI conditions requiring
surgical intervention include:
GERD
Achalasia
Esophageal Cancer
Perforation of the Esophagus
GERD
Indications for Surgery
Failure of medical management to treat GERD
symptoms, resulting in Barretts, bleeding, aspiration
pneumonia, or exacerbation of pulmonary disorders
Infants with severe reflux resulting in failure to thrive
GERD
Surgical Interventions
Nissen fundoplication: Performed laparoscopically or
open. The gastric fundus is wrapped 360 degrees
around the distal esophagus and sutured into place;
increasing the tone of the lower esophageal sphincter.
Complications: inability to burp or vomit; “Gas Bloat
Syndrome” which includes distention, inability to
vomit, abdominal pain, severe irritability; slipped or
failed surgery occurring in 0.9 – 13% of patients
GERD
Other surgical procedures
Jejunal feeding tube placement
Belsey Mark IV repair
Hill Posterior Gastropexy
Ongoing research therapies
Injectable LES implants
Gastric placations (enhances the LES)
Radiofrequency energy application to the LES
Endoscopic valvuloplasty (intussusception of the GE
junction into the stomach)
Achalsia
Achalasia is the absence of peristalsis of the esophageal
body and increased LES pressures
Indications for Surgery
Inadequate response to theraputic (slow eating,
chewing well, increased fluids during meals, and
sitting up to eat), medical management (esophageal
dilatation and botox injections)
Achalasia
Surgical Intervention
Heller’s Myotomy: Performed laparoscopically or open.
Laparoscopic approach favored R/T shorter hospital stay,
decreased risk of post op GERD, improved esophageal
emptying, and fewer episodes of dysphagia.
Surgical procedure is described as follows: “Surgical incisions
are made to the anterior and posterior portions of the distal
esophageal musculature extending into the gastric cardia.
The muscle tissue is then divided longitudinally to the
mucosal layer allowing for relaxation of the lower
esophagus.” May also see a Nissen performed at the same
time to decrease possibility of reflux.
Esophageal Cancer
Surgical intervention requires accurate and careful
staging performed typically by endoscopic ultrasound.
Surgical resection is treatment of choice for tumors
involving the distal two-thirds of the esophagus.
Surgical resection has demonstrated cure rates of 5-20%
at 3-5 years post diagnosis. Questions remain
regarding the use of chemotherapy and radiation to
prolong and improve cure rates.
Esophageal Cancer
Surgical Intervention
Surgical removal of esophageal cancer is accomplished
by “an abdominal incision…and the stomach and
duodenum are mobilized. The thoracic esophagus is
then identified and the diseased area excised. An
esophageal replacement procedure maybe indicated…
There is usually a gastric pull-through that attaches
the stomach to the proximal esophagus.”
Esophageal Cancer
Complications include recurrence of cancer at the
anastomotic sites, esophageal stricture, GERD, and
dysphagia.
Treatment for complications include esophageal
dilatation
Other Treatment Options
Endoscopic Mucosal Resection (EMR): use of saline
submucosally to raise the affected area and then
resection of it through the use of a specialized cautery
loop technique.
Perforation of the Esophagus
Causes: use of esophageal instrumentation, surgery,
foreign body, penetrating trauma, ulcers, ingestion of
caustic substances, infections (Herpes Simplex Virus
or TB), malignancy, vascular abnormalities (aortic
aneurysm, aberrant right subclavian artery) and
Boerhaave’s Syndrome ( thoracic esophagus is torn
completely away from the gastric cardia)
Perforation of the Esophagus
Symptoms
Cervical perforation: neck pain, muscle spasm, cervical
motion pain, dysphonia, hoarseness, and cervical
dysphagia
Thoracic perforation: dysphagia, odynophagia, dyspnea,
cyanosis, chest discomfort
Other symptoms may include fever, abdominal rigidity,
increased heart rate and increased respiratory rate.
Hypotension is a “late and ominous sign if impending
shock and circulatory collapse.”
Perforation of the Esophagus
Treatment
Stabilization of respiratory status
Antibiotics
Volume replacement, TPN
Chest tube placement and drainage
Surgical repair with suture then pleural, intercostal, or
diaphragmatic flaps (used in distal injuries of the
esophagus)
Perforation of the Esophagus
Complications
Dependent upon size of tear and repaired area
Dysphagia
Airway difficulties
GERD
Esophageal stricture
Other Conditions of the Esophagus
Esophageal atresia (EA): esophagus ends in a blind
pouch; congenital malformation; slightly more common in
boys; occurs 1 in 4000 births; associated with
tracheoesophageal fistula (open communicating
channel between the trachea and esophagus) in 85% of
cases.
Treated by surgical ligation of the TEF and end to end
anastomosis of the esophagus via right thoracotomy, or
self-expanding removable stents or adhesives.
Complications include dysphagia, anastomotic leak,
recurrent TEF, GERD, esophageal stricture, respiratory
compromise, inability to manage respiratory secretions.
Stomach Disorders
Most common disorders of the stomach requiring
surgical intervention include:
Hiatal hernia
Morbid obesity
Peptic ulcer disease
Perforated peptic ulcer
Pyloric stenosis
Gastric cancer
Hiatal Hernia
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Sliding Hiatal Hernia
Most common approximately 95%
Widening of the hiatal tunnel and laxity of the phrenoesophageal membrane, allowing a portion of the gastric
cardia to “slide” or herniate upwards
Paraesophageal Hernia
5% of hernias
GE junction remains in place but the gastric fundus is the
leading part of the herniation.
Very large and other organs (small intestine, spleen, or
colon) may herniate as well.
Hiatal Hernia
Surgical repair includes “reduction of the herniated
portion of the stomach through an abdominal incision
and hiatal repair with sutures” and/or mesh. The GE
junction is fixed beneath the diaphragm.
Fundoplication is generally included.
Morbid Obesity
Two types procedures currently being performed
Vertical banded or silastic ring gastroplasties (Lap-Band™)
Roux- en-Y Gastric Bypass
Morbid Obesity
Vertical banded gastroplasty: a staple line is placed
across the fundus and to the lesser curvature of the
stomach; thereby reducing stomach capacity and
creating a sensation of fullness. Less popular now r/t
outlet obstruction and fistulization of the suture line.
Silastic ring (Lap-Band™): a laparoscopic procedure in
which a silastic ring is placed at the top of the
stomach creating a pouch. The opening is adjustable
via a subcutaneous port and saline injection under
fluoroscopy or in the physician’s office.
Morbid Obesity
Roux-en-Y Gastric Bypass: performed primarily
laparoscopically. The small intestine is divided 15-40
cm downstream from the Ligament of Treitz and Roux
limb will attach to the gastric pouch. A pouch (approx
15-20 ml in size) is created at the base of the esophagus
in the stomach and the jejunum is then brought up to
the stomach pouch. The distal limb anastomoses to
the pouch and the proximal limb to the small bowel.
Morbid Obesity
Complications of weight loss surgery include
malabsorption syndromes including iron deficiency
anemia, lactose intolerance, “dumping syndrome”,
excessive weight loss, diarrhea, perforation,
anastomotic ulcers and stenosis, ulceration of the
band into the lumen of the stomach.
Patient education should include careful dietary
instruction and vitamin supplements.
Peptic Ulcer Disease
Typically able to be treated conservatively with the
discovery of H. Pylori and the role of aspirin and
NSAIDS in the development of antral and duodenal
ulcers.
Surgery indicated in emergency situations and when not
responsive to conservative treatments
Peptic Ulcer Disease
Three types of surgery:
 Partial gastrectomy to reduce number of parietal cells
in the stomach decreasing acid production
 Antrectomy to abolish the gastric phase of secretion
and to promote gastric emptying
 Selective vagotomy to negate the cephalic phase of
secretion and to reduce parietal cell sensitivity to
secretory stimulus
Peptic Ulcer Disease
The three specific surgeries are:
 Billroth I: the distal portion of the stomach, pylorus,
and duodenal bulb is removed and the duodenum is
reattached by anastomosis with the remaining portion
of the stomach
 Billroth II: the distal portion of the stomach and a
portion of the proximal duodenum is resected. The
remaining proximal duodenum is closed and a
segment of the proximal jejunum is attached to the
gastric remnant with an end-to-end or side-to-side
anastomosis.
Peptic Ulcer Disease
 Vagotomy: frequently included with both Billroth
procedures. When a truncal vagotomy is performed, a
complete denervation of the stomach as well as the
gallbladder occurs. A “highly selective vagotomy” may
be performed which interrupts the nerve fibers to the
antrum but preserves the innervation of the pylorus
resulting in decreased acid production but motility is
maintained.
Peptic Ulcer Disease
Complications of the surgeries include:
 Weight loss
 Iron deficiency anemia
 Macrocytic anemia
 Reflux gastritis
 Diarrhea
Perforation of Peptic Ulcer
Signs and symptoms:
 Generalized epigastric pain, with pain referral to the
shoulder
 Abdominal tenderness with guarding, rigidity
 Absent bowel sounds and progressive abdominal
distention
Diagnosis made by acute abdominal x-ray series and
findings of free air under the diaphragm and air-fluid
levels in loops of the small bowel.
Perforation of Peptic Ulcer
Surgical treatment maybe laparoscopic or open in nature
with repair of the perforation by suture, omental
pouch or fibrin fixatives. The potential exists for any
of the previous discussed surgeries to occur dependent
upon the extent of the perforation
Pyloric Stenosis
 Common disorder in infants: Occurrence 3 in 1000
live births in US; 4:1 male and Caucasion dominant
 Symptoms include projectile, nonbilious emesis
leading to dehydration, metabolic alkalosis, and
malnutrition
 Diagnosed with upper GI series or ultrasound
 Surgical intervention includes pyloromyotomy
(incision of the muscle surrounding the pylorus via
open abdominal incision)
Pyloric Stenosis
 In adults occurs as a result of chronic ulceration and
scarring of the pyloric channel and duodenum
 Non-surgical treatment includes dilatation
 Surgical treatment includes truncal vagotomy and
Billroth I
Gastric Cancer
 Surgical resection only treatment offering long term
chances of survival
 Extent of surgery dictated by location and size of
tumor
 EUS helpful in determining the type of surgery
required
 EMR is indicated when cancer is confined to mucosal
layer of the stomach and without lymph node
involvement
 Wedge resection maybe performed as well
Gastric Cancer
Total gastrectomy indicated for the following:
 Length of neoplasm is less than required to obtain
clear margins
 Lesion involves 2 0r 3 sections of the stomach
 Wide spread cancer
 May also include a Roux-en-Y procedure
Billroth I indicated for the following:
 Cancers in the distal portion of the stomach
Pancreatic Disorders
Chronic pancreatitis
 Resection is performed because it is believed to decrease or
eliminate pain
 Indications include severe pain impacting quality of life and
persistent pain despite abstinence of alcohol and administration
of nonopioid analgesics.
 Surgical options include distal pancreatectomy, Whipple
procedure with subtotal pancreatectomy, or total
pancreatectomy (least performed), pancreaticduodenectomy
(causes fewer metabolic deficiencies)
 Resection maintains drainage of ducts of Wirsung and Santorini
as well as tributary ducts within the head of the pancreas
Pancreatic Disorders
Pancreatic cancer
 Only 50% of pancreatic cancer patients are free of
metastases and only 20% have a curable resectable cancer
 Most common procedure is Whipple’s procedure or
pancreaticoduodenectomy : removal of 50% of the
stomach, all of the duodenum and proximal jejunum,
resection of the pancreatic head, neck, and uncinate
process and the gallbladder and biliary tree.
 Modified Whipple’s leaves stomach and 2-4 cm of the
proximal duodenum (preserves acid inhibiting hormones
thus preventing post-op ulcers)
Pancreatic Disorders
Pancreatic cancer (continued)
 Third option for surgery is pylorus preserving
pancreaticoduodenectomy: the second, third and
fourth portions of the duodenum; the neck, head, and
uncinate process of the pancreas; and gallbladder and
distal biliary tree are removed.
 Three anastomoses are required : end-to-end
pancreaticojejunostomy, an end-to-end
hepaticojejunostomy, and end-to-end
duodenojenuostomy
The Hope for Cancers of the
Stomach and Pancreas
Endoscopic Ultrasound holds the best hope for early
detection and treatment for gastric and pancreatic
cancers.
“Early diagnosis and accurate staging allows planning for
optimal care and greater chance for survival.”
Biliary Tract Disorders
 Cholecystitis as a result of cholelithiasis is the most
common indicator for surgery of the biliary tract –
cholecystectomy more often done laparoscopically than
open.
 ERCP may be indicated before or after cholecystectomy
when stones are identified in the duct by cholangiogram
 Procedures than maybe performed during open
cholecystectomy include choledochostomy(opening of the
CBD to explore for stones for obstruction), sphinceroplasty
(intractable obstruction or stricutre of the ampulla), and
choledochoenterostomy (a side-to-side anastomosis of the
CBD to the first part of the dupdenum when the
gallbladder has already been removed and obstruction of
the CBD continues to occur)
Small Intestine Disorders
Resection of Small Intestine occurs for multitude of reasons:
 Congenital anomalies, ie. duodenal atresia, jejunal atresia,
ileal atresia, gastrochisis, omphalocele
 For infants, necrotizing enterocolitis
 For children and adults, trauma, obstruction, infection,
ischemia, or Crohn’s Disease
Resection is the removal of the affected area and end-to-end
anastomosis; but when the length of the affected area or
poor tissue integrity is present, a temporary or permanent
ostomy may be required.
Small Intestine Disorders
Complications that may occur as result of small bowel
resection include:
 Stricture
 Adhesions and scarring
 Diarrhea
 Malnutrition
Degree of malnutrition depends upon length of
resection and location
May require total parenteral nutrition
Small Intestine Disorders
Surgery for Crohn’s Disease is not entered into lightly
and only occurs in those patients not responding to
aggressive medical treatment.
Indications include: intestinal obstruction, fistula,
abscess, uncontrolled hemorrhage, perforation, and
failure to thrive in children.
Ileostomy may be performed in the presence of severe
sepsis related to anorectal Crohns, with or without
abscess.
Complications associated with Crohns resection include:
diarrhea, weight loss, and recurrence of disease.
Colon and Rectal Disorders
Indications for surgical intervention in the colon and rectum
include:
 Congential anomalies
 Trauma
 Inflammatory disease
 Neoplastic disease
Common disorders requiring surgery include:
 Hirschsprung’s
 Crohns
 Ulcerative colitis
 Colorectal cancer
 Perforation
Hirschsprung’s Disease
 Incidence 1 in 5000 live births with male dominance
 Congential absence of intramural ganglia (resulting in
loss of motor function) in the intestinal tract most
frequently of the anorectum and various lengths
within the distal colon
 Treatment involves removal of the affected area
Hirschsprung’s Disease
Three surgical types
 Rectosigmoidectomy (Swenson’s procedure): removal
of the rectum and anastomosis of the normal bowel to
a 1-2 cm rectal cuff
 Retrorectal transanal pull-through (Duhamel’s
procedure): the aganglionic rectum is left in place and
the normal bowel is pulled down behind the rectum
and through an incision in the posterior rectal wall at
the level of the internal sphincter
 Endorectal pull-through (Soave’s procedure)
Hirschsprung’s Disease
Complications of the surgery include:
 Anal stenosis
 Obstructive symptoms
 Fecal incontinence
 Constipation
 Enterocolitis
Inflammatory Bowel Disease
Crohns and ulcerative colitis both affect the large bowel,
but only ulcerative colitis affects the large bowel. For
ulcerative colitis, surgery is the only definitive cure for
the disease.
Inflammatory Bowel Disease
Indications for colectomy include:
 Uncontrolled hemorrhage
 Severe colitis refractory to aggressive medical therapy
 Toxic megacolon
 Stricture
 Perforation
 Persistent symptoms despite high dose corticosteroid therapy
 Progression of disease or new onset of complications while on
maximum medical therapy
 Significant treatment related complications
 Possible malignant stricture or fistula in patients with Crohns
Inflammatory Bowel Disease
Elective colectomy may occur under the following
conditions:
 Prolonged dependence on steroids
 Complications related to steroid use
 Growth retardation despite nutritional support
 Sexual maturation
 Epithelial dysplasia (increased risk for carcinoma)
Inflammatory Bowel Disease
The surgical procedures required for UC include the
following procedures:
 Abdominal colectomy
 Rectal mucosectomy
 Endorectal ileoanal pull-through (c/i for Crohns)
 Anastomosis
The above are performed in the following stages:
 Colectomy
 Ileoanal anastomosis with creation of rectal pouch
 Diverting ileostomy
 Closure of ileostomy after 2-6 months and confirmation of
rectal tone as evidenced by manometry
Inflammatory Bowel Disease
Complications associated with these surgeries include
 Diarrhea
 Perianal irritation
 Incontinence
 Anastomotic strictures
 Inflammation of the rectal pouch (pouchitis)
Colorectal Cancer
Surgical intervention requires removal of the adjacent
mesentary, 12 regional lymph nodes, and affected
segment of the colon
Right hemicolectomy indicated for cancers in the cecum
and ascending colon
Left hemicolectomy indicated for cancers in the splenic
flexure
Anterior resection indicated for cancers in the sigmoid
or rectosigmoid area
Perforation of the Colon
May occur as a result of acute inflammatory bowel
disease, inserted foreign bodies, penetrating trauma
including both endoscopic and surgical in nature.
Potentially life-threatening requiring prompt
recognition and intervention including surgery.
Those most at risk for perforation in the endoscopy lab
are those who take immunosuppressive medications
Perforation confirmed by x-ray demonstrating free-air
under the diaphragm
Perforation of the Colon
Signs and symptoms include:
 Fever
 Abdominal or rectal pain
 Abdominal distention and rigidity
 Increased heart rate
 Increased respiratory rate
 Hypotension is late sign and indicative of impending
shock and circulatory collapse
Perforation of the Colon
Treatment includes:
 Stabilization of respiratory status
 Antibiotic therapy
 Resuscitative measures, ie. fluid replacement
 Surgery including closure of the perforation with
sutures and irrigation of the abdominal cavity
Complications include:
 Anastomotic strictures
 Bowel incontinence
 Anal strictures
Transgastric Surgery
NOTES procedures
Natural Orifice Transluminal Surgery
Potential procedures include tubal ligation,
oophorectomy, cholecystectomy, gastrojejunostomy,
and appendectomy
Who will come first - surgeon or the gastroenterologist?
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