Laura Habighorst RN CAPAHeartland Regional SGNA

April 27, 2011

Objectives1. Identify common GI disorders that require

surgical intervention2. Describe common surgical procedures

performed for GI disorders3. Identify complications associated with

surgical interventions4. Discuss nursing interventions related to

treating patients who have undergone surgery for GI disorders.

Gastroenterology Nursing: A Core Curriculum, 2008. Chapter 32: Surgical Interventions

Esophageal Disorders

Most common esophageal GI conditions requiring surgical intervention include:

GERDAchalasia

Esophageal CancerPerforation of the Esophagus

GERDIndications 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

GERDSurgical 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

GERDOther surgical procedures

Jejunal feeding tube placementBelsey Mark IV repair

Hill Posterior GastropexyOngoing research therapies

Injectable LES implants Gastric placations (enhances the LES)

Radiofrequency energy application to the LESEndoscopic valvuloplasty (intussusception of

the GE junction into the stomach)

AchalsiaAchalasia 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)

AchalasiaSurgical 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 CancerSurgical 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 CancerSurgical 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 CancerComplications include recurrence of cancer at

the anastomotic sites, esophageal stricture, GERD, and dysphagia.

Treatment for complications include esophageal dilatation

Other Treatment OptionsEndoscopic 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 EsophagusSymptoms

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 EsophagusTreatment

Stabilization of respiratory statusAntibiotics

Volume replacement, TPNChest tube placement and drainage

Surgical repair with suture then pleural, intercostal, or diaphragmatic flaps (used in

distal injuries of the esophagus)

Perforation of the EsophagusComplications

Dependent upon size of tear and repaired areaDysphagia

Airway difficultiesGERD

Esophageal stricture

Other Conditions of the EsophagusEsophageal 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 DisordersMost common disorders of the stomach requiring surgical intervention include:

Hiatal herniaMorbid obesity

Peptic ulcer diseasePerforated peptic ulcer

Pyloric stenosisGastric cancer

Hiatal HerniaSliding Hiatal Hernia

Most common approximately 95%Widening of the hiatal tunnel and laxity of the

phreno- esophageal membrane, allowing a portion of the gastric cardia to “slide” or herniate upwards

Paraesophageal Hernia5% of herniasGE 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 HerniaSurgical 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 ObesityTwo types procedures currently being

performed

Vertical banded or silastic ring gastroplasties (Lap-Band™)

Roux- en-Y Gastric Bypass

Morbid ObesityVertical 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 ObesityRoux-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 ObesityComplications 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 DiseaseThree 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 DiseaseThe 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 DiseaseVagotomy: 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 DiseaseComplications of the surgeries include:Weight lossIron deficiency anemiaMacrocytic anemiaReflux gastritisDiarrhea

Perforation of Peptic UlcerSigns and symptoms:Generalized epigastric pain, with pain

referral to the shoulderAbdominal tenderness with guarding, rigidityAbsent 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 StenosisCommon 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 ultrasoundSurgical 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 dilatationSurgical treatment includes truncal vagotomy

and Billroth I

Gastric CancerSurgical resection only treatment offering

long term chances of survivalExtent of surgery dictated by location and

size of tumorEUS helpful in determining the type of

surgery requiredEMR is indicated when cancer is confined to

mucosal layer of the stomach and without lymph node involvement

Wedge resection maybe performed as well

Gastric CancerTotal gastrectomy indicated for the following:Length of neoplasm is less than required to

obtain clear marginsLesion involves 2 0r 3 sections of the stomachWide spread cancerMay also include a Roux-en-Y procedure

Billroth I indicated for the following:Cancers in the distal portion of the stomach

Pancreatic DisordersChronic pancreatitisResection is performed because it is believed to

decrease or eliminate painIndications 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 DisordersPancreatic cancerOnly 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 DisordersPancreatic 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 DisordersCholecystitis 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 DisordersResection of Small Intestine occurs for multitude of

reasons:Congenital anomalies, ie. duodenal atresia, jejunal

atresia, ileal atresia, gastrochisis, omphaloceleFor infants, necrotizing enterocolitisFor children and adults, trauma, obstruction,

infection, ischemia, or Crohn’s DiseaseResection 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 DisordersComplications that may occur as result of small

bowel resection include:StrictureAdhesions and scarringDiarrheaMalnutrition Degree of malnutrition depends upon length

of resection and location May require total parenteral nutrition

Small Intestine DisordersSurgery 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 DisordersIndications for surgical intervention in the colon

and rectum include:Congential anomaliesTraumaInflammatory diseaseNeoplastic diseaseCommon disorders requiring surgery include:Hirschsprung’sCrohnsUlcerative colitisColorectal 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 DiseaseThree 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 DiseaseComplications of the surgery include:Anal stenosisObstructive symptomsFecal incontinenceConstipationEnterocolitis

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 DiseaseIndications for colectomy include:Uncontrolled hemorrhageSevere colitis refractory to aggressive medical therapyToxic megacolonStricturePerforationPersistent symptoms despite high dose corticosteroid

therapyProgression of disease or new onset of complications

while on maximum medical therapySignificant treatment related complicationsPossible malignant stricture or fistula in patients with

Crohns

Inflammatory Bowel DiseaseElective colectomy may occur under the

following conditions:Prolonged dependence on steroidsComplications related to steroid useGrowth retardation despite nutritional

supportSexual maturationEpithelial dysplasia (increased risk for

carcinoma)

Inflammatory Bowel DiseaseThe surgical procedures required for UC include the

following procedures:Abdominal colectomyRectal mucosectomyEndorectal ileoanal pull-through (c/i for Crohns)AnastomosisThe above are performed in the following stages:ColectomyIleoanal anastomosis with creation of rectal pouchDiverting ileostomyClosure of ileostomy after 2-6 months and

confirmation of rectal tone as evidenced by manometry

Inflammatory Bowel DiseaseComplications associated with these surgeries

include DiarrheaPerianal irritationIncontinenceAnastomotic stricturesInflammation of the rectal pouch (pouchitis)

Colorectal CancerSurgical 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 ColonMay 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 ColonSigns and symptoms include:FeverAbdominal or rectal painAbdominal distention and rigidityIncreased heart rateIncreased respiratory rateHypotension is late sign and indicative of

impending shock and circulatory collapse

Perforation of the ColonTreatment includes:Stabilization of respiratory statusAntibiotic therapyResuscitative measures, ie. fluid replacementSurgery including closure of the perforation

with sutures and irrigation of the abdominal cavity

Complications include:Anastomotic stricturesBowel incontinenceAnal strictures

Transgastric SurgeryNOTES procedures

Natural Orifice Transluminal SurgeryPotential procedures include tubal ligation,

oophorectomy, cholecystectomy, gastrojejunostomy, and appendectomy

Who will come first - surgeon or the gastroenterologist?

THANK YOU!!!!!!

WHOOH!

NOW WE ARE DONE!!