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Surgical Procedures & Post-op Care

Fundoplication

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Hospital Stay

1-2 days (Laparoscopic)

2-5 days (Laparotomy or “open”)

Procedure Overview

In a fundoplication procedure, the fundus (i.e., the upper portion of the stomach) is wrapped around the esophagus. This fortifies the LES, limiting the amount of acid that can reflux into the esophagus

Incisions

Laparoscopy: Usually 5 small incisions Laparotomy: midline abdominal incision Dressings off POD 1 and keep OTA

Postop Care

  • Tubes/Drains

    • Pt. usually have NG tube vs G tube. The G-tube is usually for large hernias/intrathoracic stomachs. Both tubes should be taped well. Pay attention to NGT to avoid pressure on the nostril (can cause necrosis). NGT may cause nausea and may delay esophageal emptying of contrast on esophagram.

    • Keep on LIWS for 1-2 days. If esophagram ordered, keep NG until study is reviewed and pt. has no nausea or bloating.

    • If patient has a G-tube, they will be discharged home with it in place. It is IMPORTANT to instruct the pt to unclamp the tube and open to gravity ONLY for SEVERE bloating/abd pain. The more often the tube is opened, the longer the tube is needed.

  • Diet

    • Pt should be strict NPO until swallow study or when NGT is pulled. Do NOT advance diet on your own. There is a lot of postop swelling at the GE junction after surgery, so food moves through very slowly. Takes an average of 4-6 weeks for swelling to go down.

    • Pts will be d/c’d on a full liquid diet & advance to a soft diet as outpatient; usually back to regular diet at 3-4 weeks

    • HOB 30° at all times

    • Strict aspiration precautions should be followed. Pt. must be up in chair for all PO intake.

    • ALL pills must be crushed & taken with applesauce/yogurt (pills can get stuck in the esophagus & erode or cause stricture, especially ASA & K+ supplements)

    • Pt. should ambulate at least TID in hospital; encourage walking for increased gastric motility and to aide recovery

    • No lifting >10lb for at least 6 weeks postop

Medications

  • Review home meds. All pills must be crushed or capsules opened and taken with applesauce or pudding. DO NOT CRUSH EXTENDED RELEASE MEDS; contact pharmacy to find an alternative medication until pills can be taken whole (usually 1-2 weeks postop).

  • Bowel care is of vital importance

    • MiraLax daily until having daily BMs

    • Colace or other stool softener while taking narcotics

    • Reglan to prevent gastroparesis (or low dose 250mg Erythromycin)

    • May try Relistor for narcotic-related constipation

    • Magnesium citrate for refractory constipation

  • Pain meds

    • PPIs

» These should be weaned over 1-2 weeks after discharge to avoid acid hypersecretion/rebound phenomenon with abrupt cessation

    • Liquid oxycodone for postop pain

» Hard to fill at outside pharmacy, so try to have it filled at our pharmacy prior to d/c or order Norco and have pt. crush it

 

Post-op Complications

Early:

  • Bleeding (watch for tachycardia/ B/P)

  • Infection (watch for fever/leukocytosis)

  • Ileus/Constipation Late:

  • Dysphagia (< 2% all cases)

  • Recurrence of hernia/reflux

  • Bloating or early satiety (rare)

ESOPHAGECTOMY

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Hospital Stay

Generally, 1 week

Procedure Overview

The majority of the esophagus is removed, the stomach pulled up through the hiatus and attached to the remaining proximal esophagus (through an incision in the neck or chest). Important! Pts. who have had an esophagectomy lose their normal protective mechanism when eating, so are at high risk for aspiration.

Incisions

Midline abdominal laparotomy or laparoscopic incisions L neck, R chest, or both

Postop Care

  • Tubes/Drains

    • Feeding J tube

  • To gravity until trickle feeds around POD 3

    • Flush J tube with 30cc warm water at least TID. If clogged, may attempt  Viokase 20mg + sodium bicarb 324mg mixed with 5ml warm water. Let dwell for 20 min

    • R chest tube, L chest tube, or both

  • CTs to suction, then water seal around POD 2

    • NG tube or retrograde G tube

  • Keep to LIWS, DO NOT REPOSITION OR REINSERT TUBE. Do not check residuals of the J or NG

    • Blake drain

  • Diet

    • NPO until POD 5-7, or after esophagram is cleared

    • Start with grape juice and monitor for purple output from tubes

    • CLD, advance to FLD over 2-3 days.

    • Pt will go be discharged on FLD and will advance to soft diet as an outpatient over weeks

    • Trickle tube feeds POD 2 or 3 then slowly advance

    • Nocturnal tube feeds from 1800-0800, usually the day before DC

    • Keep pt. “tanked up” to perfuse the stomach (critical to avoid dehydration or blood pressure). LR & 5% Albumin are used for fluid boluses to keep SBP 110-130.

    • Never start an esophagectomy patient on vasopressors or inotropes! If they need pressors something is wrong and it requires an immediate call to the thoracic attending!

    • Observe pt. for abdominal dissension/bloating/fullness

    • Record output of JP & chest tubes Q4hr

    • An upright swallow study is ordered POD 5-7 to check for leaks. If no leak found, the NG is removed and pt is started on a clear liquid

  • diet for 2-3 days. Pt. will be discharged on a full liquid diet & advance slowly as an outpatient.

    • PT. MUST BE UPRIGHT IN A CHAIR FOR ALL PO INTAKE AND FOR 2 HRS AFTER (the neo-esophagus is a gastric tube in the chest that empties slowly!)

Medications

  • Review home meds. All pills must be crushed or capsules opened and taken with applesauce or pudding. DO NOT CRUSH EXTENDED RELEASE MEDS; contact pharmacy to find an alternative medication until pills can be taken whole (usually 1-2 weeks postop)

  • Keep pt ‘tanked up’ to perfuse conduit. AVOID HYPOTENSION

    • LR and 5% albumin for fluid boluses to keep SBP>110

  • PPIs are critical for the rest of the pt’s life. Once a day is sufficient

  • Bowel care (e.g., MiraLax, Relistor, Reglan, Colace)

 

Post-op Complications

  • Conduit complications

    • Anastomotic leak

    • Conduit ischemia

    • Anastomotic stricture

  • Recurrent laryngeal nerve injury – Hoarse voice

  • Chylothorax

    • High output ≥1L per day (or >10ml/kg)

  • Less likely to respond to conservative treatment. Consider thoracic duct embolization or surgical ligation

    • Conservative treatment for low output leak includes:

  • NPO or at least NON-FAT diet

  • Tube feeding with MCT

  • Octreotide 100mg SC TID

PNEUMONECTOMY

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Hospital Stay

5 days

Procedure Overview

The entire lung on one side is removed, meaning the heart now has to pump all blood through the remaining lung, which poses significant physiologic stress to the pt. The mediastinum tends to move toward the space where the lung used to be. We try to avoid this by “balancing the mediastinum” via the chest tube. Aspiration, PE, & post- pneumonectomy pulmonary edema are usually FATAL, as the patient now only has one lung. DVT prophylaxis is critical.

Incisions

Posterolateral thoracotomy, Hemi-clamshell

Post-op Care

  • Tubes/Drains

    • Balanced chest tube or regular chest tube

      • Usually clamped overnight and removed on POD 1

      • Never put a regular chest tube atrium to wall suction in a patient that had a pneumonectomy.

    • NG tube for aspiration precaution. We are slow to remove it and start liquids. Get a speech eval.

  • Diet

    • CLD postop, then ADAT (look for air bubble on CXR; if significant, do not advance PO feeds)

    • Must be in chair for all POs

  • SCDs & subq heparin always (PE precautions)

  • Ambulate TID and encourage incentive spirometry early. OOB to chair on day of surgery, if possible

  • We minimize fluids and liberally use Lasix in the first few days in an effort to keep the pt in a negative fluid balance to avoid pulmonary edema (note: this is the opposite protocol than for an esophagectomy)

  • Important to notify MD if any change in sats (e.g., pt requiring more O2). This could be a sign of pulmonary edema

Postop Complications

  • Post-pneumonectomy pulmonary edema

    • 3x more common after RIGHT pneumonectomy

    • > 50% mortality

    • Tachypnea and hypoxia usually precede radiographic changes

  • Post-pneumonectomy  syndrome

    • Shifting of the mediastinum after pneumonectomy with compression of the contralateral bronchus between the mediastinum and the spinal column (often a late complication)

  • Chylothorax

  • Acute hemothorax

  • BPF

  • Arrhythmia

  • Gastroparesis

LOBECTOMY

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Hospital Stay

2-3 days (VATS)

4-5 days (Thoracotomy)

Procedure Overview

A portion (lobe) of the lung is taken out.

Postop Care

  • Chest tube may or may not be on suction. Check postop orders for clarification

  • Pts usually have epidural for pain control. (Stays in until chest tubes out, unless ordered otherwise.) Foley until epidural discontinued

  • Avoid “drowning the lungs.” IV’s kept at a min. May use vasopressors

for B/P support. If needing pressors, check Hct. Blood can collect in the thoracotomy chest wall and be “hidden”

  • Aggressive pulmonary toilet. (Ambulate early, encourage incentive spirometry, and fiberoptic bronchoscopy may be needed to facilitate airway hygiene, especially in current smokers)

  • Notify MD if pt requires increasing amount of O2 to maintain sats (could indicate PE)

  • Clear liquids when pt is awake the day of surgery; advance as tolerated to regular diet on POD 1

  • Follow strict aspiration precautions. Pt up in chair for ALL PO. Remember—these pts have had a part of their lung removed; PNAs are therefore much more serious

    • Fluid resuscitation and replace chest tube output with 1:1 Normal saline as long as sodium within normal range

  • Dysphagia

  • Delayed gastric emptying

  • Reflux

  • Dumping syndrome

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