Study Notes for Gl Surgeries: Hiatal Hernia, Whipple, and Bariatric Surgeries
Gl Surgeries Overview
High-level overview of surgical procedures discussed:
Hiatal Hernia Surgeries
Whipple Procedure
Bariatric Surgeries
Hiatal Hernia
Definition
Hiatal Hernia: A condition where the upper portion of the stomach bulges upward through the diaphragm into the chest cavity, caused by the weakening of the diaphragm along with increased intra-abdominal pressure.
Types of Hiatal Hernia
Type I:
Also known as sliding hiatal hernia, where the gastroesophageal junction moves above the diaphragm.
Type II:
Paraesophageal hernia, where part of the stomach pushes through the diaphragm alongside the esophagus without involving the gastroesophageal junction.
Type III:
A combination of Type I and II, with both the gastroesophageal junction and part of the stomach moving above the diaphragm.
Type IV:
A rarer type involving other organs (e.g., colon) herniating through the diaphragm into the thoracic cavity.
Risk Factors
Conditions that increase intra-abdominal pressure:
Obesity
Pregnancy
Coughing
Straining during bowel movements
Lifting heavy objects
Other risk factors:
Advancing age (>50 years)
Smoking
Trauma
Previous surgery in the abdominal area
Congenital elements (inherited conditions)
Medical Management
Recommendations to manage symptoms include:
Eating smaller meals to minimize stomach volume.
Avoiding stimulants that increase gastric secretion (caffeine, alcohol).
Quitting smoking due to its effect on gastric acid.
Steering clear of fatty foods to prevent reflux and delayed gastric emptying.
Remaining upright for at least 1 hour after eating.
Weight loss for obese individuals.
Avoiding bending from the waist and tight clothing.
Urgency for patients to seek care for acute chest pain, as it may indicate incarceration of a paraesophageal hernia.
Surgical Management
Nissen Fundoplication:
Used for severe gastroesophageal reflux disease (GERD) or hiatal hernia, this procedure reinforces and tightens the esophageal sphincter.
Post-Operative Considerations:
Potential for inability to vomit or belch
Risk of dysphagia (difficulty swallowing)
Potential post-operative infection
Whipple Procedure (Pancreaticoduodenectomy)
Description
Surgical procedure that removes the head of the pancreas, the first part of the small intestine, the gallbladder, and the bile duct.
Indications for Whipple
Malignant Conditions:
Pancreatic cancer
Bile duct cancer
Cancer located near the pancreas or duct
Benign Conditions:
Chronic pancreatitis
Pancreatic cysts
Benign tumors
Post-operative Care
Essential components of post-operative management:
Complete bowel rest initially
Gradual advancement of diet
Pain management
Blood glucose management
Repletion of pancreatic enzymes
Complications
Possible post-operative complications include:
Temporary or permanent diabetes
Bowel leakage
Organs leakage
Bleeding
Infection
Digestive difficulties
Weight loss
Bowel movement changes (constipation)
Bariatric Surgery
Overview
Surgical reduction of gastric capacity or absorptive ability aimed at producing long-term weight loss in patients with morbid obesity.
Surgical Qualifications
Patients must meet certain criteria:
Have a BMI > 40 or > 35 with at least one co-morbidity
Previous diet and exercise must have proven ineffective over 6-12 months
Must be psychiatrically stable
Must not gain weight during evaluation period
Must demonstrate dedication to lifestyle changes and follow-up
Insurance approval often takes up to 6 months, influenced heavily by criteria.
Perioperative Considerations
A multidisciplinary approach is essential, including:
Surgeon
Registered dietitian
Psychiatrist
Anesthetist
Operating room staff
Registered Nurses (RNs) and Nurse Practitioners (NPs)
Unique patient considerations:
Cardiorespiratory status
Co-morbidities
History of surgical issues
Current medications
Airway management
Possible sleep study if not done recently
Full laboratory workup
ECG (Electrocardiogram)
Assessment for DVT (deep vein thrombosis) risk and prophylaxis
Post-operative Complications
Risks following bariatric surgery include:
Bowel obstruction
Dumping syndrome
Malnutrition
Hypoglycemia
Gallstones
Vomiting
Acid reflux
Ulcers
Hernias
Requirement for revision or second surgeries
Mortality risk
Types of Bariatric Surgery
Various procedures are available:
Roux-en-Y Gastric Bypass
Sleeve Gastrectomy
Biliopancreatic Diversion
Adjustable Gastric Banding (LAP-BAND)
Procedure Details
Roux-en-Y Gastric Bypass:
The most common form of gastric bypass, it is largely restrictive and mildly malabsorptive by creating a small gastric pouch directly connected to the small intestines.
Sleeve Gastrectomy:
Approximately 80% of the stomach is removed, leading to a long, tube-like pouch, no reattachment to the intestines is required.
Biliopancreatic Diversion:
Two-part surgery:
First, a procedure akin to sleeve gastrectomy is performed.
Second, connects the end portion of the intestine to the duodenum near the stomach, effectively bypassing a substantial part of the intestine.
Adjustable Gastric Banding:
Currently, the LAP-BAND is the only FDA-approved band in the US. An adjustable band is placed around the upper part of the stomach to create a small pouch, adjusted to achieve the desired weight loss.
Post-operative Nursing Management
Nursing considerations include:
Intravenous fluids (IVF) management
Pain management
DVT/PE (pulmonary embolism) prophylaxis
Imaging performed 24-48 hours post-surgery to check for anastomotic leaks, the most common serious complication.
Monitoring for signs of infection, including: abdominal pain, restlessness, and unexplained tachycardia.
Dietary Restrictions After Surgery
Initial Dietary Protocols
Full Liquid Diet: Until the first post-operative appointment (immediate post-surgery).
Approved items: water, skim milk, strained cream soups, low-sodium clear broths, protein shakes, sugar-free drink mixes, decaffeinated coffee, or teas.
Pureed Diet: Typically begins one week after the first post-operative visit.
Approved food includes: carrots, green beans, broccoli, cauliflower, potatoes, canned chicken or tuna, cream soups, cottage cheese, and blended canned fruit.
Duration: Two weeks.
Soft Foods Diet: Commences on the fourth week post-surgery.
Approved items include: cooked non-stringy vegetables, canned fruit, soft cooked chicken, fish, eggs.
Avoidance of bread and rice is advised.
Duration: Two weeks.
Trial-and-Error: Initiates six weeks post-surgery, gradually integrating additional foods like salads, uncooked vegetables, and other meats back into the diet.
Lifelong dietary guidelines should be adhered to for sustained success.
Dumping Syndrome
Overview
Common complication affecting up to 50% of bariatric surgery patients, characterized by rapid gastric emptying.
Symptoms
Symptoms experienced:
Flushing
Crampy diarrhea
Palpitations
Diaphoresis (excess sweating)
Triggers
Often triggered by food or drinks high in refined sugar, as well as fatty and fried foods.
Timing of Symptoms
Early Dumping: Occurs within 10-30 minutes post-eating.
Late Dumping: Occurs 1-3 hours post-eating.
Nutritional Deficiencies Following Bariatric Surgery
Common Deficiencies
Post-surgery patients may experience deficiencies in:
Protein
Iron
Vitamin B12
Vitamin B1 (Thiamine)
Folate
Calcium
Fat-soluble vitamins (A, D, E, K)
Magnesium
Zinc
Copper
Selenium
Factors Contributing to Deficiencies
Contributing elements:
Reduced intake of food
Malabsorption, especially with diversionary surgeries
Non-compliance with prescribed supplements
Pre-existing nutritional deficiencies before surgery
Prevention and Management Strategies
Recommendations for prevention and management include:
Consulting with a registered dietitian for personalized supplement plans
Choosing nutrient-dense foods
Increasing protein intake
Ensuring adequate hydration
Regular blood tests to monitor deficiencies and nutritional status.