QUESTIONS & ANSWERS
GERD, ACID REFLUX,
TODAY'S SURGICAL NURSE 1997: 19 (#1); pp. 22-28.
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QUESTIONS & ANSWERS
|GERD, ACID REFLUX,|
|SAGES GUIDELINES FOR SURGICAL TREATMENT OF GERD|
* Gastroesophageal reflux disease is common, and curable with surgery.
* A minimally invasive technique offers patients with heartburn lasting relief.
* Laparoscopic technique has enhanced heartburn surgery, resulting in minimized pain and recovery time.
Permanently dousing the fire of heartbum without the use of medications may be possible with a minimally invasive surgical technique. Laparoscopic "heartburn surgery" offers patients with moderate to severe symptoms immediate, permanent relief.
With this technique, patients experience only a 2- to 3-day hospital stay, five tiny marks, a 5-to 7-day recovery period, and minimal recuperative pain.
Figure 1: Laparoscopic view of the anterior vagus nerve as it courses down along the lesser curve of the stomach on the surface of the gastrohepatic omentum. Here, the left lobe of the liver has been elevated with a retractor.
Gastroesophageal reflux disease is a condition in which stomach acids surge upward from the stomach into the esophagus. Acid reflux occurs when the muscle that acts as a valve separating the stomach and the esophagus does not stay shut.
Normally, the "valve" remains closed at all times, until swallowing forces it open, to prevent reflux. When this muscle relaxes, it allows stomach acids to seep up into the esophagus.
"When taking a breath, a negative pressure is generated in the chest," explained Garth Ballantyne, MD, PC, FACS, FASCRS, Director of The Center for Advanced Laparoscopic Surgery, St. Luke's Roosevelt Hospital, New York, NY.
"This tends to suck the stomach's contents, which have a positive pressure, up into the negative pressure zone."
According to Ballantyne, about 40% of people who have gastroesophageal reflux have a hiatal hernia. Under that circumstance, part of the stomach is slid up through a small opening in the diaphragm into the chest.
When a breath is taken, the contents of the stomach can be pumped up into the esophagus rather than the esophagus squeezing shut.
Figure 2: Laparoscopic view of the gastrohepatic omentum. The left lobe of the liver has been elevated with a retractor. The white band of the anterior vagus nerve is visible running obliquely along the lesser curve of the stomach. At the top of the photo, the white fibers of the hepatic branches of the vagus nerve are seen running horizontally toward the liver. The caudate lobe of the liver can be seen through the avascular and transparent window within the gastrohepatic omentum.
In laparoscopic fundoplication, a new "valve" is constructed as the upper portion of the stomach (fundus) is wrapped around the lower end of the esophagus. The wrap is intended to support the sphincter muscle so that it will open only when it is supposed to and not allow stomach acid to push its way up into the esophagus.
If a patient also has a hiatal hernia, the hemia is repaired before the wrap is accomplished.
"Then, whenever the patient has something in his or her stomach, the pressure generated is transmitted to the collar wrapped around the esophagus, compressing the esophagus further," Ballantyne said.
"Therefore, the more pressure inside the stomach, the greater the pressure inside the esophagus."
Figure 3. Incision of the avascular window of the gastrohepatic omentum with electrocautery scissors.
Traditional Nissen fundoplication, developed in the 1950s, required a 6- to 10-day hospital stay, a 6- to 10-inch scar, a 6- to 8-week recovery period, and significant recuperative pain.
The procedure had a number of negative side effects, principally problems with swallowing after the operation; often, people experienced worse symptoms than they had with the reflux.
"Over the past 20 years, several surgeons worked out the problems with the traditional operation," said Ballantyne.
"The solution to the technical aspect happened to coincide with the development of laparoscopic surgery and the better availability of some tests to help select the patients for the operation."
About 1991, a convergence of three factors suddenly made laparoscopic Nissen fundoplication for
the treatment of gastroesophageal reflux very attractive:
1. The surgical technique had been improved.
2. Systems to select surgical candidates accurately were developed.
3.The n-iinimally invasive technique made it a much less morbid procedure and allowed people to get back to work much sooner.
Figure 4: Entering the lesser sac through the gastrohepatic omentum. Electrocautery scissors have cut a hole through the avascular window of the gastrohepatic omentum. The caudate lobe of the liver is visible through this incision.
Recent studies focused on laparoscopic treatment of gastroesophageal reflux.
These studies were deemed necessary as the procedure is gaining popularity and few long-term studies have compared it with traditional treatment.
Morbidity was not significantly different between patient groups experiencing laparoscopic vs. traditional fundoplication in one study.
Hospital stay and recovery period were dramatically reduced in the laparoscopic group.
Dysphagia, a common symptom of reflux disease, was found to improve after laparoscopic Nissen fundoplication in a separate study.
Another study followed the first 100 recipients of laparoscopic Nissen fundoplication for reflux disease, and reported that the procedure is safe and efficient.
Surgical Laparoscopy & Endoscopy 1996; 6: 424-440.
In the laparoscopic technique, a trocar is used to gain access to the abdomen. A laparoscope is inserted through the trocar, giving the surgeon a magnified view of the patient's intemal organs on a monitor.
During the operation, the video laparoscope provides magnification making visualization of the anatomy much easier. The location of the hiatus made visualization difficult with traditional incisions.
In the procedure, the video camera goes right up there and visualization is superior than with the traditional approach," Ballantyne commented.
"As a result, the operation is easier for the surgeon than having to make a large incision. "
Because of the magnification, tiny blood vessels that surgeons traditionally ignored and cut through appear large; the surgeon tends to be much more meticulous in maintaining hemostasis during the operation. Therefore, blood loss tends to be minimal.
After one of these operations, in fact, no change can be detected in the preoperative and postoperative hematocrit. Blood transfusions are extremely rare.
Figure 5: Laparoscopic view of the lesser sac. The gastrohepatic omentum has been incised with electrocautery scissors. The caudate lobe of the liver is fully exposed. The fascia overlying the right crus is seen to the patient's left of the caudate lobe. The vena cava is barely visible behind the lower edge of the caudate lobe.
The first part of the operation reduces the hiatal hemia in patients with the hernia.
Ballantyne noted that the "[reduction] is done by freeing the esophagus and the stomach of surrounding soft tissue connections around the hiatus and pulling the stomach and about 5 or 6 cm of the esophagus down into the abdomen.
"The muscles of the left and right crura are then approximated with typically two or three sutures placed behind the esophagus. This serves to tighten the hiatus back to a normal size so that the squeezing action generates a positive pressure, helping to block the reflux of stomach contents up into the esophagus."
The second part of the operation strengthens the function of the lower esophageal sphincter at the junction of the esophagus and the stomach. According to Ballantyne, this is done by freeing the fundus of the stomach of its connections, for example, the short gastric vessels to the spleen.
"Sometimes, little ligaments connect it to the left diaphragm. Those are freed up and a window is made behind the esophagus; this allows the surgeon to pull the redundant portion of the fundus of the stomach from the left side behind the esophagus to the right side and then around the front of the esophagus so that it is sewn to itself, typically with three stitches," he explained.
"The stitches would involve the right side of the fundus that has been pulled through; then, the anterior surface of the esophagus; and finally, the left side of the fundus.
"The three sutures usually span a distance of about 2 cm. If the span is longer, there are difficulties with swallowing after the operation," Ballantyne said.
The combined procedures prevent reflux in almost everyone.
Figure 6: The short gastric vessels between the greater curve of the stomach and the spleen are divided with the Endo-GIA 30 (USSC) stapling device. The anterior surface of the stomach is just visible at the bottom; the spleen is on the right side. This increases the mobility of the fundus of the stomach and allows construction of the fundoplication without tension on the esophagus
1. Nearly half of recurrent heartburn sufferers who responded to a recent survey would consider surgery for heartburn if there was minimal pain, disability, and recovery time, as well as a real cure.
2. The survey of heartburn sufferers revealed that 45% of respondents would consider surgery to correct the disorder.
3. According to the survey, heartburn affects patients adversely in many areas, including: sleep (65%); dining out (58%); household chores (52%); exercise (51 %); work (50%); leisure activities (46%); travel (44%); and sex (34%).
4. Heartburn occurs daily for'; 34% of respondents; for 1 0%, the heartburn has lasted for more than 25 years.
5. More than half of respondents indicated that they take at least two over-the-counter medications for heartburn.
6. Twenty percent have gone to the hospital or doctor thinking that the heartburn was a more serious medical condition.
United States Surgical Co (USSC)
The procedure must be performed as a team effort. Three groups-nursing, anesthesia, and the surgeon-must work together and provide mutual support.
From a nursing point of view, the instruments used for the operation are different than for most other operations. Therefore, specialized instruments must be set up.
As with any procedure, a flow must be maintained. Everyone must be familiar with the procedure.
Anesthesia attention is important because the principal determinant of length of stay is the response of the patient to the anesthesia. "If the patient wakes up bucking and coughing or retching," commented Ballantyne, "he or she may stay in the hospital 2 or 3 days."
If extubation is smooth and the patient is not nauseated and can drink liquids that night, the patient is ready to go home the next moming.
Figure 7. The fundus of the stomach is pulled behind the esophagus from the patient's left side to the right. Two grasping instruments are holding up the fundus on either side of the esophagus to check that an adequate amount of fundus has been mobilized to allow a tension-free construction of the fundoplication. The left lobe of the liver and the left diaphragm are visible in the background.
The primary function of the assistant is to assemble everything needed for the surgery so all instruments will be on hand for the surgeon, according to Edwin Olivares, the surgical technologist who assists Ballantyne with laparoscopic Nissen fundoplication at St. Luke's.
"The instruments, including the monitors, must be prepared and checked to make sure that they are in good working order before the patient is brought into the room," said Olivares.
As the laparoscopic approach is used for the Nissen fundoplication, several special instruments and
accessories are necessary. This instrumentation includes:
* two monitors;
* an ultrasound machine;
* specialized telescopes, O' angle and 30' angle;
* antifogging for the telescopes, so they do not become cloudy during the procedure;
* five trocar ports;
* an instrument to grasp the intestines, to prevent perforation;
* endoshears and endoclips;
* a five-finger endoretractor;
* specialized needles and scissors;
* disposable dissectors; and
* equipment for positioning the patient.
The laparoscopic procedure is quite detailed, but everything is kept under control when done routinely. The same protocol is followed for the procedures, including ultrasound and videotaping.
"In the operating area, the assistant's role is to help the surgeon with the instrumentation, passing the instruments, keeping everything organized, and helping in any way needed," said Olivares.
At the end of the procedure, the five small incisions made for the trocar ports are closed; in a few weeks, the scars are almost invisible and it is not obvious that the patient had surgery.
Overall, essentials must be up to par and everything on hand to keep the procedure running smoothlyotherwise, there is a chance for delay, and time, as in most settings, is of importance.
Figure 8: The fundoplication is constructed by suturing the fundus in a 360' collar around the esophagus. Here, the left and right sides of the fundoplication are sutured to each other in front of the esophagus. The left lobe of the stomach is visible in the background.
The reflux symptoms disappear immediately after the surgery. "From the moment the patient has the operation," said Ballantyne, "he or she no longer is taking medications-and usually, the patient was taking a lot of medications before surgery."
As with other minimally invasive operations, there is little pain following the procedure because of the small incision. Thus, people tend not to need much in the way of pain medication postoperatively.
People usually come into surgery the moming of the operation and go home the next day. Some elderly patients stay 2 or 3 days, but typically, it is a short stay procedure.
In some locations, the surgery is performed on an ambulatory basis, according to Ballantyne.
People can return to work or normal activities in 2 weeks.
After surgery, some patients experience trouble swallowing and feel a soreness in the throat. This usually disappears after a few days. Some patients feel full sooner and cannot eat as much as they could before the operation.
The most important postsurgical consideration is swallowing. Because of the surgery right around the hiatus and the junction of the esophagus and the stomach, some swelling can be anticipated; thus people may have some swallowing problems for 2 or 3 weeks after the operation.
As a result, patients are kept on a diet that is easy to swallow. The diet includes soft and well lubricated foods.
"Some foods that seem easy to swallow, like bread, tum out to be the hardest. Dry and fibrous foodssuch as vegetables like celery-are hard to swallow," said Ballantyne.
"Solid foods must be soft and well lubricated, so mashed potatoes with butter or ketchup or soggy french fries with ketchup are recommended.
"Pasta with creamy sauces are allowed, but with no chunks of vegetables added." Ballantyne noted that soups are permitted, "but not vegetable soups, because chunks of vegetables again can be a problem."
Most people probably can start eating the day after surgery, but as the occasional person has difficulty swallowing and it is such an unpleasant experience to get something caught in the throat, Ballantyne prefers to keep everyone on the limited diet for a couple of weeks.
Within 3 weeks, all patients are back on a regular diet.
Although 44% of all U.S. adults have symptoms of reflux at least once or twice a month, only a small percentage of people require surgery.
This procedure effectively treats symptoms of gastroesophageal reflux other than moderate-to-severe heartbum, including regurgitation of food, hoarseness of voice, and adult asthma caused by aspiration of food from reflux.
"People who might be considered for surgery are those who fail on medical therapy and continue to experience symptoms despite taking antacid therapy with medications like Prilosec and Propulsid," explained Ballantyne.
"Young people who find relief from the medications but do not want to take medicine for their entire life span also are good candidates for the procedure," he added.
Others who may find the surgery useful are individuals who cannot tolerate strong antacid medications due to allergies or side effects and those who have developed complications of reflux such as strictures of the esophagus.
Garth Ballantyne, MD, PC, FACS, FASCRS, is founding Director of The Center for Advanced Laparoscopic Surgery and Chief of the Division of Laparoscopic Surgery, St. Luke's Roosevelt Hospital, New York City.
Edwin Olivares is a surgical technologist at St. Luke's Roosevelt HospitaL
Mary Evangelisto is Associate Editor of Today's Surgical Nurse.