CGRN (Core Curriculum) Latest Version Graded A+

CGRN (Core Curriculum) Latest Version Graded A+ Therapeutic Procedures Achalasia occurs when nerves of the esophagus do not function properly, resulting in problems swallowing and passing food thru the lower esophageal sphincter (LES) -Sx is only done if pt has no relief from meds or EGD procedures -Sx is a MYOTOMY (open sx or laparoscopic), surgery consists of circular muscle fibers of the LES that are divided. -Laparoscopic Heller's Myotomy is the "most popular" and used "most frequent." Has less morbidity, complications, and better recovery. -Peroral Edoscopic Myotomy (POEM) endoscopic procedure which performs myotomy without surgery. -Steps of the Procedure include: a. find the LES and mark it inject it with dye b. make longitudinal incision with an electrocautery knife c. tunnel the scope into the submucosa space. The tunnel is created beyond the LES into the proximal stomach, exposing the inner circular muscle layer. d. Perform the myotomy about 8 to 10 cm above the GE junction and 2 to 3 cm into the cardia. -Pt's with severe achalasia and failure of myotomy will need to have an esophagectomy, which is last resort and risky. Therapeutic Procedures Billroth I Procedure the antrum is resected and the duodenum is reanastamosed to the gastric remnant. (ex. Perforated Peptic Ulcer). -not used as much as laparoscopic procedures -Complications include: a. anastomotic and suture leaks resulting in peritonitis and or sepsis -Side effects include: a. dumping syndrome b. diarrhea c. bile reflux gastritis Therapeutic Procedures Boerhaave's Syndrome the lower thoracic esophagus is completely torn away from the gastric cardia. -some pt's may have vomiting, difficulty breathing, and tachycardia, depending on location of perforation. a. Cervical-neck pain and muscle spasm, cervical motion pain, dysphonia (spasm/tone), hoarseness, cervical dysphagia. b. Thoracic-dysphagia, odynophagia (painful swallowing), dyspnea, cyanosis, and chest discomfort. -Early tx for esophageal perforation incudes: a. stabilize respiratory status b. antibiotics c. volume replacement d. (TPN) Total Parenteral Nutrition e. chest tube drainage -When surgery is necessary, usually the esophagus tear requires sutures. a. The sutured area is reinforced with pleural or intercostal flaps in a thoracic injury b. The sutured area is reinforced with a diaphragmatic flap in the lower esophageal tear Therapeutic Procedures Billroth II Procedure the distal portion of the stomach and the proximal duodenum are resected, and the jejunum is reanastamosed to the gastric remnant. (ex,Perforated Peptic Ulcer). -not used as much as laparoscopic procedures -Complications include: a. anastomotic and suture leaks resulting in peritonitis and or sepsis -Side effects include: a. dumping syndrome b. diarrhea c. bile reflux gastritis Therapeutic Procedures Endoscopic Mucosal Resection (EMR) can remove "early stage" cancer that is confined to the mucosal layer without any lymph node involvement. -if this removes the cancer successfully than this eliminates the need for surgery Therapeutic Procedures Endopscopic Ultrasound (EUS) Therapeutic Procedures Gastroplication Therapeutic Procedures Esophageal Atresia (EA) congenital malformation affecting 1:2,500 live births, usually boys. -the esophagus ends in a blind pouch instead of attaching to the stomach. -most cases, (EA) is associated with (TEF) Tracheoesophageal Fistula. -TEF is an open communication channel between the trachea and esophagus. -"Most preferred" treatment is a endoscopic procedure using self-expanding stents. -Surgical treatment involves ligation of the TEF and an end-to-end anastamosis of the esophagus thru a right thoracotomy. -(EA) repair complications include: a. dysphagia b. anastomotic leak c. recurrent TEF d. GERD e. esophageal stricture -(TEF) repair complications include: a. respiratory compromise b. inability to manage respiratory secretions Therapeutic Procedures Gastroesophageal Reflux Disease (GERD) the lower esophageal sphincter (LES) does not close properly, allowing stomach contents to flow backwards into the esophagus. -can be treated endoscopically or surgically -Gastroplication-is a pleat in tissue that is secured by an intraluminal suturing device. They are placed in the stomach at or just below the squamocolumnar junction to enhance the competency of the LES and prevent reflux. -Sx and endoscopic procedures are only done when meds/diet etc. fail to relieve symptoms, leading to Barrett's or bleeding. -Life-threatening symptoms of GERD are aspiration pneumonia, pulmonary disease exacerbation, bradycardia. -infants are prone to GERD b/c immature LES and being on liquid diets. Usually resolves at age 2 when started on solids. So surgery is not needed unless emergent. -Nissen Fundoplication-"most common" surgical procedure for GERD in both kids and adults. a. can be done by laparotomy or laparoscopy the gastric fundus is wrapped 360 degrees around the distal esophagus and sutured in place, creating a tightened LES. b. Complications from Nissen includes: 1. unable to belch or vomit 2. gas bloat syndrome 3. recurrence of symptoms that may require another Nissen procedure. (failed of slipped Nissen). Therapeutic Procedures Heller's Myotomy Therapeutic Procedures Whipple Procedure a.k.a Pancreaticoduodenectomy -treatment for pt's with pancreatic cancer. -removes 50% of the stomach, all of the duodenum, and the proximal jejunum. The pancreatic head, neck and uncinate process are resected along with the gallbladder and distal biliary tree. -In the pylorus-preserving Whipple-the 2nd, 3rd, 4rth portions of the duodenum; the neck, head and uncinate process of the pancreas; gallbladder and distal biliary tree are removed. -3 anastamoses are necessary for reconstruction: a. end-to-end whipple b. end-to-end hepaticojejunostomy c. end-to-end duodenojejunostomy -Modified Whipple Procedure-leaves the entire stomach and 2-4 cm of the proximal duodenum, preserving peptic acid-inhibiting hormones and preventing post-op peptic ulceration. -Complications include: a. leaking from various connections between organs b. infection c. bleeding d. difficulty with stomach emptying after eating e. difficulty digesting some foods f. weight loss g. change in bowel habits h. diabetes Therapeutic Procedures Nissen Fundoplication "most common" surgical procedure for GERD in both kids and adults. a. can be done by laparotomy or laparoscopy the gastric fundus is wrapped 360 degrees around the distal esophagus and sutured in place, creating a tightened LES. b. Complications from Nissen includes: 1. unable to belch or vomit 2. gas bloat syndrome 3. recurrence of symptoms that may require another Nissen procedure. (failed of slipped Nissen). Therapeutic Procedures Pancreaticoduodenectomy aka Whipple Therapeutic Procedures Pyloric Stenosis common disorder in infancy. -effects about 3:1,000 live births, mostly white male infants. -Hypertrophic Pyloric Stenosis- occur by 3-6 weeks of age and will have projectile non-billious emesis. a. can lead to dehydration, metabolic alkalosis, malnutrition. b. diagnosed by GI series and U/S c. Treatment of choice in infants is Pylorotomyotomy, where a incision is made around the muscle surrounding the pylorus. This is done via abdominal incision. -In adults, chronic ulcerations with subsequent scarring in the pyloric channel and duodenum can result in pyloric stenosis and gastric outlet obstruction. -pyloric stenosis can also be caused by inflammatory edema surrounding an acute channel ulcer. -In adults, treatment may include dilation. a. surgery in adults is indicated when pyloric stenosis is secondary to PUD. A gastric outlet drainage procedure (Billroth I) may be indicated to treat the underlying cause of PUD. Therapeutic Procedures Roux-en-Y Gastric Bypass a restrictive and malabsorptive procedure for morbid obesity. -restrictive-means limits of the amount of food to be ingested. -malabsorptive-means impact the absorptive qualities of the GI system so weight loss can occur rapidly. -can be done laparoscopic or surgical -with laparoscopic, pt can be d/c home within 1 to 2 days. (this procedure cannot be reversed). Steps of the procedure include: a. stomach is sectioned off into a 30ml pouch. b. duodenum is divided off the jejunum and the jenunal limb (Roux) is brought up and attached to the stomach pouch. c. the duodenal limb is then anastomosed to the remaining jejunum. -b/c Roux-en-Y sx causes "dramatic" wt loss, pt's lose 60% to 80% body wt, thus nutrition/lifestyle changes need to be addressed. -High-protein, low-carbs and small portion sizes are required. -Life-long vitamins include: Vitamin B-12, iron, calcium, folate. (a decrease in intrinsic factor, so need Vit B-12). -Complications include: a. leakage along suture lines b. anastomotic ulcers and stenosis c. long-term nutritional deficiencies d. excessive weight loss e. dumping syndrome Therapeutic Procedures Sliding Hiatal Hernia the "most common" type of hiatal hernia. (accounts for 90% of them). -occurs when the GE junction moves above the diaphragm. The stomach remains in it's normal position with the fundus below the GE junction. -when meds do not work, surgery is then done. -Surgery is a Nissen Fundoplication and usually done laparoscopically. A mesh may be placed to reinforce the placement of the GE junction below the diaphragm. a. usually same day surgery b. decrease complications c. decrease morbidity Tracheoesophageal fistula (TEF) open communication channel between the trachea and esophagus. Transgastric Surgery uses natural orifices for the entry point for surgery -Natural Orifice Translumenal Endoscopic Surgery (NOTES)-uses natural orifices such as mouth, vagina, rectum as the entry point to the peritoneum, making Transgastric surgery possible. a. allows laparoscopic procedures such as cholecystectomy, appendectomy, and bariatric surgery to be done thru natural orifices. b. NOTES procedure steps: 1. sterile environment 2. double-channel endoscope with sterile overtube inserted into the stomach. 3. incision is dilated with an 18 mm balloon dilator. 4. surgical procedure performed, with proper instruments. 5. incision closed by clips, sutures or possibly surgical adhesive. Chronic Pancreatitis 3 elements to treatment: a. determining the definite diagnosis b. treating any underlying jaundice or duodenal obstruction with an endoscopic approach c. remove all the inflamed area or tumor of the pancreas -resection is based on a belief that removal of the diseased tissue decreases or eliminates pain associated with pancreatitis, as well as further complications. -2 surgical options includes: (both surgeries allow drainage from the biliary tree and the pancreatic duct to occur). a. Pylorus-preserving whipple b. Duodenal-preserving pancreatic head resection -Severe pain associated with chronic pancreatitis can be effectively treated with surgery. By doing surgery early in the disease can decrease amount of opioid meds used to manage pain. Pancreatic Cancer 4rth leading cause of cancer death with a 5 year survival rate of 5%. -At the time of diagnosis, only 50% of pts with pancreatic cancer don't have other mets. 10% to 15% have localized disease that can be cured by resection. -Panceatic cancer usually is found in: a. head b. neck c. uncinate process of the gland -3 stages of pancreatic cancer disease: a. resectable disease b. locally advanced disease c. metastatic disease -Surgical treatments include: (which procedure to use is determined by size and location of tumor). a. Whipple b. distal pancreatectomy- removes the tail and portion of the body of the pancreas c. total pancreatectomy -removes the entire pancrease -if pancreatic cancer is found before nodal spread, than the Whipple procedure is a effective treatment. -survival rate increases with adjuct therapy including chemo and/or radiation. a. many pt's do better when chemo and radiation are used to shrink the tumor mass prior to surgery. -EUS is used to diagnose and stage pancreatic cancer. a. diagnosis can be made much earlier with fine needle aspiration (FNA). -genetic and biomarker testing can also offer early diagnosis and accurate staging. -Complications from Whipple include: a. leaking from various connections between organs b. infection c. bleeding d. difficulty with stomach emptying after eating e. difficulty digesting some foods f. weight loss g. change in bowel habits h. diabetes