Websurg, e-Surgery 關於腹腔鏡手術

GASTROESOPHAGEAL REFLUX DISEASE: POSTOPERATIVE MANAGEMENT OF ANTI-REFLUX SURGERY

1. Postoperative pain management

• treat the pain before its onset;
  
• avoid nausea and vomiting (additional source of pain and potentially detrimental to the surgical repair)
  

1. An analgesic ketamine dose (0.5 mg/kg, KETALAR®) is injected during the anesthesiologic induction in order to antagonize the NMDA receptors. (NOTE: there is no effect on the patient’s level of consciousness at these doses).
   
2. Excellent curarization and analgesia during the operative procedure. Injection of 1 mg of Droperidol (DROLEPTAN®).
   
3. Non-opioid analgesics used about 30 min. before the end of the anesthesia:
   
   • NSAID (e.g. Ketoprofen, 50 to 100 mg) (there are no side effects at these doses, notably on hemostasis);
     
   • 1 g of paracetamol per rectum or 2 g of paracetamol PO.
     
4. Tramadol hydrochloride administered (postoperative pain, 100 mg initially then 50 mg every 10-20 min. if necessary during first hour to total maximum 250 mg (including initial dose) in first hour, then 50-100 mg every 4-6 hours; maximum 600 mg daily) with 0.5 mg of Droperidol for every 100 mg of Tramadol hydrochloride to prevent nausea
   
5. For breakthrough pain, morphine titration (2 to 3 mg IV morphine every 5 to 10 min. until the visual analogue scale for the assessment of pain <= 3 is reached) in the recovery room:
   
   • to anticipate nausea/vomiting, Droperidol is given with morphine (0.5 mg of Droperidol for 10 mg of morphine),
     
   • the Patient Controlled Analgesia (PCA) is rarely used: if it is, Droperidol is associated with morphine in the PCA reservoir at the dosage indicated above.
     
6. As soon as liquid intake is resumed and if no nausea or vomiting occur, soluble paracetamol is administered: 1 g every 4-6 hours.
   
7. Continue regular NSAIDs (eg, Ketoprofen 50 mg every 8 hours orally).
   

2. Early complications

Figure 2

2.1. Intrathoracic migration

• Frequency:
  

• When to suspect it:
  

• Mechanism:
  
  • Deficient crural approximation;
    
  • Undiagnosed left pneumothorax;
    
  • Large peri-esophageal and mediastinal dissections.
    
    
• What to do:
  
  • Establish diagnosis with a chest X-ray illustrating the intrathoracic migration,
    
  • Re-operate urgently to bring the fundoplication back into the abdomen, suture the crura, and fix the fundoplication to the crura.
    

Figure 2.1

2.2. Dysphagia

• Frequency:
  

• Mechanism:
  

• What to do:
  
  • Monitor,
    
  • before the operation inform the patient of the need to adapt diet.
    

Figure 2.2

2.3. Gastric denervation syndrome

• Symptoms of gastric denervation:
  

• Mechanism:
  

• What to do:
  

3. Failures

• persistent side effects hampering the quality of life (dysphagia (a), gas bloat syndrome (b), diarrhea (c): 4% to 15%),
  
• persistence or recurrence of GERD symptoms.
  

3.1. Persistent dysphagia

• Frequency:
  

• Mechanism:
  

• What to do:
  

Figure 3.1.2

• Mechanism:
  

• What to do:
  
  • begin with an endoscopic dilatation, effective in more than 50% of cases,
    
  • in case of failure after 3 dilatations, re-operate.
    

Figure 3.1.3

• Mechanism:
  

• What to do:
  
  • begin with an endoscopic dilatation, effective in more than 50% of cases,
    
  • in case of failure after 3 dilatations, re-operate.
    

Figure 3.1.4

• Mechanism:
  

• What to do:
  
  • begin with an endoscopic dilatation, effective in more than 50% of cases,
    
  • in case of failure after 3 dilatations, re-operate.
    

Figure 3.1.5

• Mechanism:
  

• What to do:
  
  • dilatation is less effective,
    
  • re-operate (more extensive dissection of the esophagus, creation of a floppy Nissen)
    

Figure 3.1.6

• Mechanism:
  

• What to do:
  

Figure 3.1.7

• Mechanism:
  

• What to do:
  
  • dilatation,
    
  • in case of failure: Heller myotomy
    

Figure 3.1.8

3.2. Gas bloat syndrome

3.3. Diarrhea

• Frequency:
  

• Mechanism:
  

• What to do:
  

4. Persistence of symptoms

• resuming long-term PPI medical treatment,
  
• repeat surgery, although this represents a major challenge due to the complexity of the procedures.