Stomach Disorders: Surgical Interventions Flashcards
What are the 6 surgical interventions for peptic ulcer disease and gastric cancer?
- Total gastrectomy
- Vagotomy
- Gastric Resection (antrectomy)
- Billroth I (Gastroduodenostomy)
- Billroth II (Gastrojejunostomy)
- Pyloroplasty
What is pyloroplasty?
- Pyloroplasty is surgery to widen the pylorus.
- Involves cutting through and removing some of the pyloric sphincter to widen and relax the pylorus.
- This makes it easier for food to pass into the duodenum.
- In some cases, the pyloric sphincter is entirely removed
What are some conditions that precipitate pyloroplasty?
- Pyloric stenosis
- Peptic ulcers and peptic ulcer disease
- Gastroparesis, or delayed stomach emptying
- Vagus nerve damage or disease
What are the two ways pyloroplasty can be performed?
- Open surgery
- Laparoscopic surgery
Describe an open pyloroplasty.
- A longitudinal incision is made along the pylorus
- Make several small cuts through the muscle of the pylorus sphincter muscles, widening the pyloric opening.
- Stitch the pyloric muscles back transversely
What gastric function does the vagus nerve serve?
• Vagus nerve fibers from the medulla stimulate the parasympathetic nervous system of the stomach which, in turn, stimulates gastric secretion
What is a vagotomy?
• A surgical operation in which one or more branches of the vagus nerve are cut, typically to reduce the rate of gastric secretion
What is a truncal vagotomy?
- This procedure cuts out part of the vagus nerve at the gastroesophageal junction
- After this surgery, the stomach won’t have nerve supply, which can reduce gastric acid to about 50%
How does the vagus nerve affect gastric motility and how is it affected by a vagotomy?
- Gastric motility is regulated through the vagus nerve
- After vagotomy the stomach becomes atonic and hypomotile
- The small intestine also receives its parasympathetic nerve supply through the vagus and vagal stimulation can cause increased motility of the small intestine.
What is a selective vagotomy?
• More precise than truncal vagotomy
• Only the part of the nerve that goes to the stomach is removed, and the vagus nerve connection to the gallbladder and intestine is left in place
o Gastric branches severed, hepatic branches preserved
What is a highly selective vagotomy?
- This procedure is also called parietal cell vagotomy and is the most precise option.
- It involves removing part of the vagus nerve only where it connects with the parietal cells in the stomach wall that release gastric acid.
- The rest of the nerve is left there where it can still stimulate the pyloric valve
What is an anastomosis?
• A connection made surgically between adjacent blood vessels, parts of the intestine, or other channels of the body, or the operation in which this is constructed.
What is a Billroth I procedure?
• The partial gastrectomy is performed with anastomosis to the duodenum
What is a Billroth II procedure?
- The partial gastrectomy is performed with anastomosis to the jejunum
- Former site of pyloric sphincter at duodenum is sewn shut
A billroth I is also called a…
• Gastroduodenostomy
A billroth II is also called a…
• Gastrojejunostomy
Explain a total gastrectomy procedure.
- The stomach and pylorus removed with anastomosis to the jejunum
- Duodenal stump is sewn shut
What is the Roux-en-Y procedure?
- Total gastrectomy procedure with an adjustment to jejunum/duodenal junction
- Former site of pyloric sphincter at duodenum is sewn shut
- Duodenum is severed from the jejunum
- Jejunum is attached to esophagus
- Duodenum is re-attached further down the jejunum
In a total gastrectomy, why is the duodenum attached further down the jejunum.
• It allows time for the digestive juices from the pancreas to travel down to the jejunum and mix with chyme before proceeding into the small intestine
Why will a pt with a total gastrectomy require Vit B12 supplementation?
• Production of intrinsic factor is removed with the stomach and unless supplements are taken, there will be a reduction in RBC production and pernicious anemia will result
What is a possible surgical complication of Billroth II and total gastrectomy, but not Billroth I?
- Duodenal stump leak
- Leakage of the blind end of the duodenum
- Typically, on the fourth or fifth day after surgery
- It is due to improper closure of duodenal stump, especially when the duodenum is inflamed and edematous.
What is gastric decompression used for?
• To control of gastric distention and vomiting
Gastric decompression protects the patient against…
• the bronchial aspiration of gastric contents
Gastric decompression encourages the adequate and rapid…
• healing of intestinal suture lines
Gastric decompression minimizes the incidence of
• Abdominal wound dehiscence and evisceration
Gastric decompression decreases the incidence of…
• postoperative adhesive obstruction
The NG tube used for gastric decompression should be no greater than ___ for ease of passage and pt safety.
• 5/8”
What kind of NG tube is used for gastric decompression and why?
- A double-lumen nasogastric tube.
- There is one large lumen for suction and one smaller lumen to act as a sump.
- A sump allows air to enter so that the suction lumen does not become adherent to the gastric wall or become obstructed when the stomach is fully collapsed
After placement of NG tube for gastric decompression or feeding, what is the priority action?
- Check placement w/ xray
- Tape down well when confirmed
What are the top 3 post-op complications of gastric surgery?
- Bleeding
- Dumping Syndrome
- Diarrhea
With gastric removal or resection, comes a decrease in intrinsic factor that reduces or eliminates vitamin b12 absorption. What conditions can result due to this?
- Iron deficiency anemia
- Pernicious anemia
- Megaloblastic anemia
- Folic acid deficiency
- Fluid and Electrolyte imbalance
How does rapid gastric emptying result in anemia?
• Decreases absorption of iron
A pt had a Billroth II and is complaining of severe abdominal pain. You observe a bile stained dressing, what do you expect is the issue?
• Duodenal stump leak
A gastric post-op pt starts to vomit while having their vitals taken. What immediate actions should the nurse take?
- Raise HOB
- Check airway
- Check breathing
- Double check NG tube placement (and that it is on)
Why do we want to prevent N/V in a gastric post-op pt?
• The pressures of vomiting can rupture incisions
How often do we run a CBC for a gastric post-op pt and why?
- Every 8hrs
- To check for electrolyte imbalance
Bleeding is the number 1 gastric post-op complication. Where and when does it typically occur?
- At the anastomosed site
- w/in the first 24hrs and
- post-op days 4-7
Besides checking the incision site/bandage, how else can we assess for bleeding in a gastric post-op pt?
• Check NG tube for stomach contents
Why is a gastric post-op pt on NG suction for the first few days after surgery?
- Should bleeding occur:
- It can be discovered immediately
- It will avoid pressure build up, thus N/V complications and prevent wound dehiscence
Bleeding is typical after gastric surgery, how are we monitoring healing via the NG tube?
- Monitor suction container for volume and color over time.
- Be sure to measure OP at the end of every shift and document amount and color
It is day 6 post gastric surgery and the pt is found to have gastric retention. What action should the nurse take?
• Insert NG tube and initiate suction
Why does gastric surgery lead to a malabsorption of fat?
- Surgery results in
- Decreased stomach acids
- Pancreatic secretions and
- Increases upper GI mobility cutting down available absorption time
When assessing gastric aspirate, when do we expect to see w/in the first 24hrs?
• Bright red blood at first, then it should darken
When assessing gastric aspirate, when do we expect to see w/in 36-48hrs?
• Color should change to yellow-green
How often are we checking VS after gastric surgery?
• Every 4hrs
What are s/s that indicate gastric post-op intestinal obstruction?
- Decreased peristalsis
- Lower abdominal discomfort
