General

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Bowel Resection

Procedure: Bowel resection (colostomy, colectomy, ex-lap, ileostomy, nissun-fundoplication).

Indication: CA, toxic mega-colon, obstruction, trauma

Description: Abdominal cavity is accessed either open or laparoscopically. Bowel is manipulated and removed as necessary, diversions are made (colostomy, ileostomy) if necessary, and abdomen is closed.

Post-op Implications:

Complications: bleeding, surgical site infection, peritonitis, ileus, mechanical bowel obstruction, uncontrolled pain, peri-stomal skin breakdown.

Meds: If colostomy/ileostomy is performed, don’t give extended release or long acting Rx. BM: supp/enema POD3 if no BM. Pain: PCA and epidural Or PCEA (bipiv/fentanyl) are most common.

Principles: Temporary ileus is an expected physiologic response from bowel manipulation. At risk for acute dehydration due to lack of h20 absorption in colon. Replace fluid lost through NG/OG with IVF to achieve normovolumea. Altered absorption can affect electrolytes.

Care Plan: Aggressive and frequent pulmonary hygiene. Ambulate and OOB POD#1. Skin care, wound care, foley hygiene, stoma care (if applicable) and pain control. Keep spare ostomy appliances at bedside.

Course of Care: POD# 1: OOB, clear liquid diet, foley out after ambulating, and NG/OG tube out after tolerating PO (if applicable). Educate pt on ostomy care.

Room Setup: Humidified 02, oral suction, standard IV-pump, possible PCA, possible epidural, SCDs, and possible suction for NG/OG tube.

ERCP

Procedure: ERCP (Endoscopic retrograde cholangiopancreatography)

Indication: Bile duct blockage, Bile duct stone removal, CA tissue sampling, Stent placement.

Description: Pt is intubated and under GA. Endoscope is passed down esophagus and used to inject dye and inspect pancreatic/gall ducts in conjunction with X-rays. Endoscope is then used to perform desired interventions such as stent, stone removal, or biopsy.

Post-op Implications:

Complications: Pancreatitis & Bacteremia: prophylactic antibiotics.

  • Bleeding: first priority is repeat endoscopic intervention, then angiographic embolization, then surgery.
  • Proximal esophageal perforations: usually can be managed with antibiotics, NPO status, and cervical drainage as needed. Duodenal perforations secondary to the endoscope may result in a large rent of the lateral wall and may require more aggressive therapy including surgical drainage, or in more serious situations, duodenal diversion techniques Biliary tree or duodenal *perforation: management can range from NPO and AbX to stents/drains or surgery.
  • Gas insufflation of duodenum can cause post-op discomfort.

Meds: Prophylactic AbX. Pt may be NPO for extended period of time depending on complications. N/V managed with antiemetic IV.

Care Plan: Wound care, strict I&O monitoring, manage IVF, Skin care, percutaneous drain care (if applicable), foley care (if applicable), pain control, early ambulation.

Course of Care: POD#1: OOB, advance diet as tolerated unless NPO, restart home Rx as able.

Room Setup: Humidified 02, oral suction, standard IV-pump, possible PCA, and, SCDs.

Gastrectomy

Procedure: Gastrectomy (total & partial)

Indication: CA & ulcers

Description: Procedure can be performed laparoscopically or open. Access to stomach is obtained, stomach is dissected from surrounding tissues and anastomosis is created between esophagus and duodenum or jejunum. A partial gastrectomy involves dissecting a portion of the stomach and using the remaining tissue to preserve intestinal continuity. With a total, most often a J-tube is placed.

Post-op Implications:

Complications:

  • Anastomic leak: swallow study can confirm a leak. CT scan can visualize extraluminal collections; these must be drained. Give systemic AbX for suspected leak. Usually ruled out by day 5-7. Small leaks can be managed with AbX, gastric decompression (NG/OG tube passed below anastomosis), and fluid drainage.
  • Postgastrectomy syndromes: dumping syndrome, weight loss, and diarrhea; usually improve after 12 months, require symptomatic treatment: supplements, antidiarrheal, and diet modification( avoid simple carbs).
  • Anastomic stricture: Usually presents as dysphagia, may require upper GI endoscopy with dilation.

Meds: IV Abx prophylaxis. All meds will be IV for first few days unless an OG/NG tube is approved for med use by surgeon. SubQ heparin. May require long-term electrolyte replacement due to decreased absorption. May require high calorie/high protein supplements.

Principles: Temporary ileus is an expected physiologic response from bowel manipulation. If NG/OB tube is in place, do not manipulate or replace if dislodged (can disrupt anastomosis). Decreased absorption leads to weight loss, dumping syndrome, and electrolyte imbalances.

Care Plan: Aggressive pulmonary toileting, skin care, wound care, foley care, pain control. Possible PCA, epidural, And J-tube care. Manage IVF. NPO until barium swallow study (may allow sips and chips). Possible NG/OG tube care.

Course of Care: POD #1 Early ambulation, NPO until POD# 2 or 3 after swallow study. Foley out after ambulating and diuresis (if no epidural). Early J-tube feedings may be initiated. After swallow study advance to CL, then soft solids. Restart home Rx as able.

Room Setup: Humidified 02, oral suction, standard IV-pump, possible PCA, possible epidural, SCDs, and possible suction for NG/OG tube.

Paraesophageal Hernia Repair

Procedure: Paraesophageal hernia repair (nissen fundoplication, gastropexy).

Indication: Hiatal hernia with GERD that is unrelieved by medical management. A paraesophageal hernia is a true herniated sack of gastric fundus within the thoracic cavity.

Description: Performed either laparoscopically or via open abdomen. The hernia is dissected and the hiatal defect is closed. A nissen fundoplication is then most often performed (wrapping of stomach around esophagus to retain competency of the lower esophageal sphincter (to reduce GERD)). A gastropexy is also most often performed (fixation of the stomach to the anterior abdominal wall (to prevent reoccurrence of herniation)).

Post-op Implications:

Complications: Herniation: Barium esophogram can detect, also CXR.

  • Bleeding: Dissection of gastric blood vessels can cause excessive bleeding, usually controlled intra-op.
  • N/V: retching from emesis can disrupt closures, needs barium esophagogram asap.
  • Gastric/esophageal perforation: Sepsis if undetected.
  • Pneumothorax: Caused by a tear in the pleura during mediastinal dissection.
  • Gas-bloat syndrome: inability to vent air from stomach and delayed gastric emptying causes discomfort.
  • Dysphagia: Most patients experience this to some degree during first 2-6weeks due to inflammation and edema slowing bolus transit of solid foods.

Meds: Antiemetics: scheduled for first 24hrs, emesis can result in disruption of the hernia repair. Pain control: Most likely PCA, if open procedure then most likely will have epidural.

Principles: Temporary ileus is an expected physiologic response from bowel manipulation. Normal bowel function may take 5 days to return.

Care Plan: Aggressive pulmonary toileting, skin care, wound care, foley care, pain control. Possible PCA, epidural, And G-tube care. Manage IVF. NPO until barium swallow study on POD 1.

Course of Care: Most likely extubated in OR. POD #1OOB, if ambulating, D/C foley. Barium swallow study, if no leak, advance diet from NPO to CL, then to soft solids, then low residue diet for several weeks.

Room Setup: Humidified 02, oral suction, standard IV-pump, possible PCA, possible epidural, SCDs, and possible suction for NG/OG tube.

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